Peritoneal Metastases: Their Associated Imaging Features

Peritoneal Metastases (PM) detection remains a challenge even with modern imaging. Knowing imaging features of abnormal findings frequently associated with PM is of interest to improve PM detection. Although ascites is a common imaging finding of PM, the presence of ascites alone, even in patients with known cancer, is not enough to diagnose PM. The peritoneum should be read as an own organ with careful analysis of the ligament (e.g. falciform and hepatoduodenal ligament), the mesos and the omenta. Indirect manifestations of visceral peritoneal involvement is a segment of small bowel fixed to the parietal peritoneum, the appearance of blockage of free circulation of ascites, plurisegmental bowel obstruction and clumped bowel that is a strong predictor of diffuse involvement of the visceral peritoneum by a high grade tumor. Ovarian and umbilical metastases are frequently associated with PM in particular in digestive cancers. Moreover, ovarian metastases has been shown to be less responsive to chemotherapy than other metastases and should not be chosen as a target lesion for RECIST assessment. The presence of cardiophrenic angle lymph nodes also increases the possibility of metastatic spread in peritoneum. Finally, the most common PM mimickers include colonic diverticulum, mesenteric lymph nodes, splenosis implants, fat necrosis and postoperative changes after cytoreductive surgery and HIPEC.

Ultrasound Assisted Neuraxial Blockade in Obstetric Anesthesia

Central Neuraxial Blocks (CNBs) relevant to the practice of obstetric anesthesia and analgesia are spinal, epidural and combined spinal-epidural injections. These techniques are routinely used for cesarean deliveries and labor pain relief. Traditionally, CNBs are performed using surface anatomical landmarks. In the first instance the highest point of each iliac crest is identifies. The imaginary line connecting these points allegedly passes through the L4 vertebral body in non-pregnant women, and L3 vertebral body in pregnant women [1]. Based on this, the operator palpates and counts the spinous processes and decides on the needle entry point. Although this technique is widely accepted as relatively reliable, the correlation is inconsistent even in non-complicated cases. Obesity, tissue edema, pelvic rotation, limited ability to bend forward, hyperlordosis, labor pain, underlying spinal deformity or previous back surgery and instrumentation pose additional difficulty for anesthesiologists to correctly locate the intervertebral levels.

Nondysraphic Intradural Spinal Lipoma: A Rare Case in a Child

Lipoma is a rare and benign tumor, with lesions associated with spinal dysraphisms. The reported case is about an 8-month-old child who arrived at the hospital with developmental delay, excessive crying, undergoing MRI and reported spinal cord lipoma. Intradural lipomas without association with dysraphism are difficult to diagnose, being the most accurate form of MRI.

Is there a Relationship between the Blood Group and the Percentage of Lung Involvement in COVID-19‘S Patients?

As a faculty member who is teaching students in the main hospital of coronavirus - Tohid hospital - in Sanandaj, Iran. I want to share my experiences in confronting the chest CT of COVID-19 patients. What we saw in chest CT of these patients was the different percentage of lung involvement in blood groups. The percentage of lung involvement in patients with blood group O was noticeably higher than other blood groups. Unfortunately, a high percentage of outpatients with high lung involvement in chest CT were old and were unaware of their blood group, therefore we cannot claim that there is a significant relationship between lung involvement and blood group in COVID-19 patients. To the best of our knowledge, clinical presentations and papers have not yet addressed this issue, therefore proof of this relationship requires clinical studies

MRI-Based Normative Measurement of the Ocular Globe Position in Relation to Inter-Zygomatic Line among Nepalese Subjects

Introduction: Proptosis and enophthalmos are cardinal signs of many orbito-ocular and systemic diseases. The need for an imaging parameter that will aid its early detection is necessary, as visual compromise is a major consequence if they are not diagnosed and managed early. Methodology: This prospective study was performed in a tertiary center. Data were collected over the period of January to April 2021 with total of 300 normal ocular globes. The measurement was done at the level of lens (midglobe section) on T2-weighted axial image. Results: The distance between the anterior margin and inter zygomatic line of the right ocular globe was 16.95 ± 1.48 mm (ranged 14.2 - 20.5 mm) and that of left was 16.86 ± 1.38 mm (ranged 14.2 - 20.3 mm). The position of the globes showed no statistically significant differences among gender groups in our study and the position of the right globe within the orbit was significantly different from that of the left orbit. Conclusion: The position of the globes showed higher values in males than in female. However, a statistically significant difference in globe position was observed between right and left orbits. The distance between the posterior margin of the globe and the inter zygomatic line was found to be lower among the Nepalese population compared with other population.

Early Cortical Laminar Necrosis on MRI

An 80-year-old man with chronic hypertension was admitted to the emergency department with consciousness disorders. The evolution was marked by a rapid worsening of his neurological condition. The patient was intubated and ventilated. The biological check-up revealed a blood glucose level of 0.2g/l. A brain scan was performed which was without abnormality. Two days after the normalization of the blood sugar level, the patient presented a late awakening. A brain MRI was performed which showed bilateral fronto-parietal laminar cortical areas in T2, Flair and diffusion hypersignal, T1 iso signal, and no hyposignal on T2 gradient echo sequence (Figure 1). The diagnostic of Cortical Laminar Necrosis was retained.

Man in the Barrel Syndrome Following TEVAR

Man-in-the-Barrel Syndrome (MIBS) is a neurological disorder characterized by the paralysis of both upper limbs without paralysis of both lower limbs or paralysis of the pathological reflex and is very rare in clinical practice. The pathogenesis of MIBS varies and includes disorders of the brain, brainstem, spinal cord or peripheral nerves. Most cases are due to intracranial lesions, and MIBS caused by cervical spinal cord ischemia is particularly rare. This study reports a case of MIBS caused by cervical spinal cord ischemia one day after Thoracic Endovascular Aortic Repair (TEVAR).

Performance of Conventional and Machine-Learning Approaches for the Diagnosis of Tumor Recurrence on MRI after Radiation Therapy of Brain Metastases

Objective: To compare the performance of conventional and machinelearning approaches for the diagnosis of tumor recurrence after radiation therapy of brain metastases. Methods: 184 symptomatic patients with solitary metastatic brain lesions treated with radiation therapy were enrolled in a monocentric retrospective study from June 2013 to May 2018. The diagnosis was tumor recurrence (n=71) and radiation necrosis (n=113) using as reference standard expert-consensus derived from pathology and long-term follow-up. 37 potential predictors were recorded at the time of radiological progression (7-15 months after therapy): 6 clinical features and 31 imaging features including 20 radiomics features derived from standard of care 3D T1-gadolinium sequences. We compared four approaches (A, B, C, D): expert report using MRI sequences without (A) and with delayedcontrast MRI (TRAM) sequences (B), 11 non-Radiomics imaging features alone (C) and a signature combining variables selected using unsupervised machinelearning algorithms (D), training:validation sets: n=144:40 pts). Results: Overall (n=184), approaches B and C (using TRAM sequence alone) reached comparable performances with respective AUCs [95% CI] of 78.7% [72.3%-85.1%] and 76.8% [70.3%-83.3%]. Both significantly outperformed approach A with AUC [95% CI] of 57.4% [50.7%-64.1%] (DeLong’s test, p-value=10-7). In the validation set (n=40), the signature reached an AUC [95% CI] of 92% [87%-97%]. Conclusion: A quantitative analysis of TRAM sequence seems the best approach for the diagnosis of recurrent tumor after radiation therapy. It is parsimonious, objective and less time-consuming than interpreting all sequences. A signature derived from the analysis of standard of care 3D T1- gadolinium sequence showed promising results that warrant prospective validation.

Superimposed High Frequency Jet Ventilation Minimises Diaphragm, Bronchus, and Mediastinum Motion during One-Lung Flooding

Background: One-Lung Flooding (OLF) represents an ideal acoustic pathway for focused ultrasound ablation of lung tumours. Despite stabilization of the adjacent hemidiaphragm by OLF, standard Pressure-Controlled Ventilation (PCV) of the contralateral lung causes an unacceptable movement of the flooded lung. We examined whether Superimposed High Frequency Jet Ventilation (SHFJV) reduces lung motion compared to PCV during OLF. Methods: The study included 15 pigs: 10 underwent OLF; 5 controls underwent two-lung ventilation without OLF. Using ultrasound, diaphragm displacement on the flooded lung side was measured during PCV and SHFJV in the left lateral (LLP), Supine (SP), and Right Lateral Positions (RLP). Bronchus and mediastinum displacements were measured in the right lateral position. Results: Diaphragm displacement on the flooded lung side was significantly reduced during SHFJV, compared with PCV, in all animal positions (LLP: 7mm [4.75-8.0] vs. 17mm [14.75-19.0], P=0.0039; SP: 4mm [3.75-4.25] vs. 17mm [16.0–18.5], P=0.0039; RLP: 8mm [5.75-9.0] vs. 20mm [14.0-23.25], P=0.0078). Displacement of both the bronchus and mediastinum were significantly reduced during SHFJV, compared with PCV, in RLP (bronchus: 2.0mm [1.75-2.25] vs. 3.0mm [2.75-3.0], P=0.027; mediastinum: 4.5mm [4.0-5.0] vs. 10mm [7.0-10.0], P=0.0078. Conclusion: Thus, SHFJV minimises diaphragm, bronchus, and mediastinum motion during OLF, which is a prerequisite for effective lung tumour ablation.

Interposition of the Anterior Tibial Tendon between the Medial and Intermediate Cuneiforms in Lisfranc Injuries: Report of Two Cases

Total lateral incongruity type Lisfranc injury may cause skin problems and compartment syndrome, manual reduction and temporary immobilization are usually needed. However, sometimes-manual reduction is not easy to achieve due to the prevention of reduction by interposed soft tissues. We report two cases of irreducible Lisfranc injuries due to interposition of the anterior tibial tendon between the medial and intermediate cuneiform bones. Our recommendation for manual reduction in total lateral incongruity with suspicion of the anterior tibial tendon’s interposition is to push up the forefoot dorsally under the distraction, abduct the forefoot, displace the forefoot medially, and adduct the forefoot in sequence.