Minor head injury in a developing country like Malaysia is managed by primary care physicians and/or medical assistants in district hospitals. These patients are seen initially in their local hospitals, which have at least an X-ray machine for the purpose of screening. This study aimed to guide these physicians to manage these patients at a primary care level. A cross-sectional study was conducted and the study revealed significant predictors of significant computed tomographic (CT) findings. The presence of a Glasgow coma scale (GCS) score of 14 or 13 was associated with the risk of developing significant CT findings compared to patients with a GCS of 15 (p<0.001). Thirty-seven out of 50 patients with GCS of 14 or 13 developed clinically significant brain injury on CT scan. Similarly, the presence of skull fracture was associated with the risk of developing CT abnormalities (p<0.001). Forty-two out of 51 patients with skull fracture developed clinically significant CT findings. Vomiting was associated with developing CT abnormalities (p=0.017). Twenty-seven out of 40 patients with vomiting showed significant CT findings. Soft tissue injury was also found to be associated with developing CT abnormalities (p=0.007). Therefore, we propose reclassifying minor head injury based on the GCS score. Patients with a GCS score of 15 were classified as having mild head injury, while patients with a GCS score of 13 or 14 were at higher risk of developing brain injury and therefore categorized as high risk mild head injury. This group requires emergency CT scan examination, especially when associated with non-motor vehicle accidents, abnormal central nervous system (CNS) examination, craniofacial injuries or skull fractures. They should be referred to a general surgical unit which can treat head injuries or a neurosurgical tertiary centre.
Tuberculosis, an ancient disease continues to be a health care burden in Malaysia in the 21st century. Extrapulmonary tuberculosis is a less common presentation of tuberculosis and in particular peripancreatic tuberculous lymphadenitis is rarely seen. We report a case of a young immunocompetent boy presenting with a two month history of non productive chronic cough associated with loss of appetite and loss of weight. Investigations including CT Scan and Endoscopic ultrasound revealed multiple mediastinal lymphadenopathy and peripancreatic lymphadenopathy with central caseation necrosis. Histology of cervical lymph node was suggestive of tuberculosis and mycobacterium PCR was positive. The patient was subsequently treated with antituberculous therapy and had marked clinical improvement of his symptoms. This case outlines a rare presentation of a common disease and the application of newer investigative tools in making the diagnosis.
Hepatocellular Carcinoma is the most common type of liver cancer having a strong relation with cirrhosis. Undoubtedly, cirrhosis may be caused by the virus infection of hepatitis B (HBV) and hepatitis C (HBC) or through alchoholism. However, even when cirrhosis has not been developed, patients with hepatitis viral infections are still at the risk of liver cancer. Apparently, among the numerous medical imaging techniques, Computed Tomography (CT) is the best in defining liver tumor borders. Unfortunately, these imaging techniques, including the CT procedures, usually rely on an appended application to reconstruct the generated 2-D slices to 3-D model. This may involve high performance computation, may be time-consuming or costly. Moreover, even with the outstanding performances of CT in defining the liver tumor boundaries, contrast between tumor tissues and the surrounding liver parenchyma is too low in CT slices. With such a close proxity in the tumor and the surrounding liver tissues, accurate characterization of liver tumor is a challenge. Previously, algorithms were developed to reveal abnormalities in brain's MRI datasets and CT abdominal pelvic, however, introducing a framework that could accurately characterize liver tumor and its surrounding tissues in CT datasets would go a long way in contributing to medical diagnosis and therapy planning of Hepatocellular Carcinoma. This paper proposes an Hepatocellular Carcinoma framework by extending the functionalities of SurLens Visualization System with an automatic liver tumor localization technique using Compute Unified Device Architecture (CUDA). The study was evaluated with liver CT datasets from the Imaging Science and Information Systems (ISIS) Center, the Georgetown University Medical Center. Significantly, visualization of liver CT datasets and the localization of the entangled tumor was achieved without prior datasets segmentation. Interestingly, the framework achieved remarkably good processing speed at a reasonably cheaper cost with an immediate reconstruction of the datasets and mapping of the tumor tissues within the surrounding liver parenchyma.
Infratemporal fossa abscess is a rare and challenging condition to diagnose and manage. A few reported cases have been mostly due to odontogenic infections and were managed by external or intraoral drainage. This is the first reported case of an infratemporal fossa abscess that was successfully managed by endoscopic drainage via a transmaxillary approach.
During extensive osteological study of 150 dry skulls in the Department of Anatomy, Vardhman Mahavir Medical college, an unusual Paramedian Occipital (POC) condyle was detected in the occipital bone of a cadaveric skull. The anatomical details of this unusual occipital condyle were carefully studied and its morphometric measurements taken. A coronal multiplanner reformatted image and a volume rendered image were taken to study radiological details and establish significant clinical correlation. Precise understanding of anatomy of craniovertebral junction and its anomalies have become immensely important for the present day surgeon during orthopaedic and neurosurgical procedures of this region . Technical advancements in imaging modalities such as CT and MRI scans further signify the importance of these anatomical variations ,which are often missed in routine examination. Osteological study combined with radiological details of the paramedian occipital condyle in the present case aims to emphasize the importance of bony anomalies in the craniovertebral region and their role in diagnosis and appropriate treatment of neurovascular compression syndromes of craniovertebral junction. The present study highlights anatomical details, clinical relevance and embryological basis of such a rare unusual paramedian occipital condyle.
We report a case 35-year-old lady who developed acute psychosis following administration of cefuroxime and metronidazole. Earliest mood changes occurred on the second day of antibiotics therapy. She developed hallucinations, delusions and bizarre behavior 1 day after the completion of the antibiotic therapy. All the relevant investigations including CT brain were normal. The psychosis resolved completely within 5 days of antipsychotic treatment.
Thyroglossal duct cyst (TDC) is a developmental anomaly that usually appears in early childhood. The common presentation is midline swelling of the neck, which moves with both tongue protrusion and deglutition. Diagnosis is usually clinical and radiological. Fine needle aspiration cytology (FNAC) can be used as a tool for the exclusion of malignancy in adult patients. In some cases thyroid scan is done to rule out the presence or absence of the normal thyroid gland. A complete work-up is mandatory before cyst removal given that it contains only thyroid tissue. We report the case of a 32-year-old woman with only thyroid tissue in thyroglossal duct cyst.
The sphenoid sinus, one of the posterior groups of sinuses, has long been regarded as a 'neglected sinus' due to the anatomical location, poor understanding and poor accessibility, till the advent of endoscopes and modern imaging techniques. Increasing knowledge and greater understanding of this sinus has permitted an evolution in surgical practices and boundaries. Various literatures of the past report a great variety of rates of pneumatization, rates of optic nerve protrusion and dehiscence, as well as internal carotid artery (ICA) protrusion and dehiscence. One similarity noted among these studies is that the rates vary according to the ethnicity of the patients. Recommendations have also been made along the way with regard to modified surgical techniques. This review aims to describe the pneumatization of sphenoid sinus and the topographical relation of the optic nerve and ICA in different populations.
The drug-trafficking business has risen tremendously because of the current increased demand for illegal narcotics. The smugglers conceal the drugs in their bodies (body packers) in order to bypass the tight security at international borders. A suspected body packer will normally be sent to the hospital for imaging investigations to confirm the presence of drugs in the body. Radiologists, therefore, need to be familiar with and able to identify drug packets within the human body because they shoulder the legal responsibilities. This pictorial essay describes the characteristic imaging features of drug packets within the gastrointestinal tract.
Synovial sarcoma is a rare soft tissue sarcoma that commonly involves the lower extremities and occurs predominantly in young adults. It very rarely occurs in the head and neck region and carries a poor prognosis. The tumor demonstrates both a loco-regional and a systemic pattern of spread that makes management challenging. Combined modality therapy of this aggressive tumor yields better results. Herein, we described a 58 years old lady presented with left parapharyngeal synovial sarcoma. This is to demonstrate the aggressiveness of the disease despite complete surgical excision followed by post operative radiotherapy. Local regional control was difficult and recurrence of disease was seen in this particular patient.
How does one decide on the best non-invasive test to investigate stable coronary ischaemia? This is a very common question faced by many medical practitioners. Chronic stable angina is a common presentation encountered in general practitice. Upon clinical assessment and risk stratification the patient needs to be investigated further to confirm the diagnosis. The first investigational modality involves a non-invasive test. It is important that practitioners possess a practical knowledge of the array of different tests that are available so that the best suited one for each patient can be chosen. This article aims to compare the efficacy and accuracy and the practical utility of the different non-invasive tests for coronary ischaemia and aid the practitioner in making sound decisions in this regard.
Radiofrequency ablation (RFA) therapy is recognised as a safe and effective treatment option for osteoid osteoma. This case report describes a 27-year-old man who underwent computed tomography (CT)-guided percutaneous RFA for a femoral osteoid osteoma, which was diagnosed based on his clinical presentation and CT findings. The patient developed worsening symptoms complicated by osteomyelitis after the procedure. His clinical progression and subsequent MRI findings had led to a revised diagnosis of a Brodie's abscess, which was further supported by the eventual resolution of his symptoms following a combination of antibiotics treatment and surgical irrigations. This case report illustrates the unusual MRI features of osteomyelitis mimicking soft tissue tumours following RFA of a misdiagnosed Brodie's abscess and highlights the importance of a confirmatory histopathological diagnosis for an osteoid osteoma prior to treatment.
An incidental finding of an intense focus of (18)F-Fluorodeoxyglucose (FDG) pulmonary uptake on positron emission tomography (PET) without detectable lesions on computed tomography (CT) is highly suggestive of FDG microembolus. Its microscopic nature means it is undetectable on CT. It is an artefact attributable to (18)F-FDG-tracer contamination at the injection site. This paper reports a case of a 61 year-old lady with a past history of breast carcinoma, in whom follow-up PET/CT images demonstrated an incidental intense FDG pulmonary abnormality. A follow-up PET/CT seven months later demonstrated complete resolution of the abnormality.
The occurrence of congenital diaphragmatic hernia in a pregnant adult is rare. In contrast to neonatal diaphragmatic hernias, most of the adult patients present with vague gastrointestinal symptoms mimicking other diseases hence the importance of high index of suspicion. We report a case of a young pregnant lady with congenital diaphragmatic hernia presenting with symptoms and clinical signs suggestive of acute pancreatitis. The patient had a laparotomy performed to reduce the hernial content and the diaphragmatic defect was successfully repaired.
Computed tomography (CT) fluoroscopy is able to give real time images to a physician undertaking minimally invasive procedures such as biopsies, percutaneous drainage, and radio frequency ablation (RFA). Both operators executing the procedure and patients too, are thus at risk of radiation exposure during a CT fluoroscopy.This study focuses on the radiation exposure present during a series of radio frequency ablation (RFA) procedures, and used Gafchromic film (Type XR-QA; International Specialty Products, USA) and thermoluminescent dosimeters (TLD-100H; Bicron, USA) to measure the radiation received by patients undergoing treatment, and also operators subject to scatter radiation.The voltage was held constant at 120 kVp and the current 70mA, with 5mm thickness. The duration of irradiation was between 150-638 seconds.Ultimately, from a sample of 30 liver that have undergone RFA, the study revealed that the operator received the highest dose at the hands, which was followed by the eyes and thyroid, while secondary staff dosage was moderately uniform across all parts of the body that were measured.
This is a case report of disseminated Penicillium marneffei infection in a patient with leprosy, responding to antifungal therapy. Radiologically there were nodules in the left lung, right pleural effusion, lymphadenopathy in neck, mediastinum and upper abdomen and abscesses in the liver and right parietal lobe. This case highlights a rare infection in a non-HIV related immunocompromised patient, and its nonspecific radiologic manifestations.
Haemangiopericytoma (HPC) is a rare vascular tumor arising from the pericytes of Zimmermann and is characterized by its unpredictable and variable biological behavior. These tumors are common in the trunk and the extremities and less than 16% of the cases occur in the head & neck region. Its occurrence in the oral cavity and pharynx is uncommon. We report an extremely rare case of haemangiopericytoma of the oropharynx arising from the tonsillo-lingual sulcus as a pedunculated mass, which was successfully excised perorally after a preliminary tracheostomy. No recurrence has been noted on a follow-up of more than six years.
Fibrous dysplasia is a benign disease characterized by a progressive replacement of normal bone elements with fibrous tissue and the temporal bone involvement is uncommon. It has a male:female ratio of 2:1 and is seen more commonly in the first two decades of life. Diagnosis is made based on radiological findings and the modality of treatment is mainly conservative. However, surgery is reserved for preserving function and preventing complications. Fibrous dysplasia in the region of craniofacial bones is of particular interest to the otolaryngologist as it causes deformity and dysfunction that can be debilitating. We present a 49 year old Chinese gentleman with complaints of chronic dizziness over the last one year and had no obvious hearing impairment. Computed tomography of the mastoid revealed fibrous dysplasia of the right temporal bone. This case is of particular interest due to the late presentation as it is more commonly seen in the first two decades of life.
A 5-month-old girl presented with a soft-tissue mass over the lateral aspect of her right eyebrow. Surgical resection revealed a diagnosis of infantile malignant hemangiopericytoma. The mass recurred after excision and reconstruction. The patient died 4 months later with brain and lung metastasis.
Atypical mycobacterium is rarely seen as a cause of chronic mastoiditis but has been increasingly recognized over the past few years. Mycobacterium abscessus is the most pathogenic and chemotherapy-resistant, rapid-growing mycobacterium of all the four groups. This paper presents a case of a 57-year-old woman who had chronic mastoiditis with recurrent exacerbations. The initial computed tomography (CT) findings showed the presence of an inflammatory process and she was treated with the appropriate antibiotics. The patient subsequently underwent a tissue biopsy when she presented with another exacerbation. At this time, the CT scan did not identify the ongoing exacerbation, but the Gallium-67 scintigraphy did.