Vol. 22, No. 2, July, 2014. 22, No. 2, July...EXECUTIVE COMMITTEE President Prof Syed Mizanur Rahman...

61

Transcript of Vol. 22, No. 2, July, 2014. 22, No. 2, July...EXECUTIVE COMMITTEE President Prof Syed Mizanur Rahman...

Vol. 22, No. 2, July, 2014

(Published in October 2016)

BANGLADESH JOURNAL OF

RADIOLOGY AND IMAGING

Annual Subscription : Tk. 200.00 for local and US$ 20.00 for Overseas Subscribers

Official Publication of Bangladesh Society of Radiology and Imaging33, Topkhana Road, Meherba Plaza, L-5th Floor, Dhaka-1000, Bangladesh

Phone : 8613189, 9126995E-mail: [email protected] Website: www.bsribd.org

EDITORIAL BOARD

Editor in Chief : 

Prof Abu Saleh Mohiuddin

Co-Editors:

Dr Shamim Ahmed

Prof Shibendu Mojumder

Col Zoherul Islam

Executive Editor:

Prof Md Mizanur Rahman

Executive Members:

Prof Md Enayet Karim

Prof Mahfuzur Rahman

Prof Farid Ahmed

Dr Delwar Hossain

Dr Mobarak Ali

Dr Sarwar Ramiz

Dr Syed Maksumul Haque

Dr Nilkantha Paul

Dr Mahmud Uz Jahan

EXECUTIVE COMMITTEE

President

Prof Syed Mizanur Rahman

Vice - President

Prof Brig Gen (Rtd) Jahangir AlamProf Md Enayet Karim

Prof Abu Saleh Mohiuddin

Secretary General

Prof Dr Md Mizanur Rahman

Treasurer

Prof Shibendu Mojumder

Joint Secretary

Dr Shahryar Nabi

Organizing Secretary

Dr Md Shahidul Islam

Office Secretary

Dr Md Khalilur Rahman

Scientific Secretary

Dr Shamim Ahmed

Secretary for International Affairs

Prof Salahuddin Al Azad

Entertainment Secretary

Dr Bishwajit Bhowmick

Members

Dr Md MofizullahDr Syed Maksumul HaqDr Bibekananda HalderDr Mahmood-Uz-Jahan

Dr Robindranath Sarker (Robin)Dr Fatema Doza

Dr Sushanta Kumar SarkarDr Bidoura TanimDr Asish Sarkar

BANGLADESH SOCIETY OF

RADIOLOGY AND IMAGING

Bangladesh Journal of Radiology and Imaging a

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CONTENTS

Editorial

l PACS (Picture archiving and communication system) 53Mariyam Sultana

Original Articles

l Comparison of Superior Mesenteric Arterial Index in Diabetic Patients with 55Pancreatic Calculi Before and After Meal and Those of Control Subjects

Fahmida Yeshmine, Mahbuba Hussain, Sharmistha Dey, Md Towhidur Rahman,

Abu Saleh Mohiuddin, Rehnuma Jahan, Khabir Ahmed, Shafiul Azam

l Correlation between Volume of Hippocampal Formation & Age, Sex of 60Adult Subjects with Normal MRI of Brain

Md Towrit Reza, Misbah Uddin Ahmed, Shahryar Nabi, Md Shahidul Islam, Khadija Begum,

Mohammed Mahbub Ullah, AKM Golam Kabir, Khabir Ahmed, Sushanta Kumar Sarkar

l Performance of Magnetic Resonance Imaging in the Diagnosis of 68Tuberculous Spondylitis

Nazma Farzana Chowdhury, Md Mizanur Rahman, Robindranath Sarker,

Maj Maksuda Khanom, Gopal Chandra Saha, Akanda Fazle Rabbi, Md Anisur Rahman

l Evaluation of Accuracy of Transvaginal Sonography in Diagnosis of 74Adenomyosis with Histopathological Correlation

Tarana Yasmin, Mashah Binte Amin, Sheuly Begum, Asish Kumar Sarkar, Aurobindo Roy,

Md Anisur Rahman Khan, Md Khalilur Rahman

l Role of Color Doppler and High Resolution Sonography in the Prediction of 81Malignant Thyroid Nodules with Cyto and Histo-pathological correlation

Maksuda Begum, Molla Ershadul Haque, Mahbub Alam, Shahidul Islam, Rasheda Pervin

Bidoura Tanim, Md Anisur Rahman

l Evaluation of Outcome of Management of Giant Cell Tumour of Bone by 88Curettage, Chemical Cauterization and Morcellized Bone Graft in Sandwich

Technique Augmentation with Bone Cement

Imam Gaziul Haque, Hasan Masud, Sk Nurul Alam, M Sajjad Hossain,

Shahryar Nabi, Shamim Ahmed

Case Reports

l Macrodystrophia Lipomatosa - Case Report 93Fonindra Nath Paul, Mohammad Mizanur Rahman, Md Anisur Rahman Khan,

Dosth Mohammad Lutfur Rahman, Zannatul Ferdous

l Isolated Polysplenia in Adult Patient-A Case Report with Review of the Literature 96Ashraf Uddin Khan, Mariyam Sultana, Shibendu Majumder

l Carotid Cavernous Fistula (CCF): A Case Report 100Syed Zoherul Alam

l Orbital Plexiform Neurofibroma – A Case Report 103Zinat Nasrin, Abul Khair Ahmedullah, Fonindra Nath Paul

BANGLADESH JOURNAL OF

RADIOLOGY AND IMAGING

Volume 22 Number 2 July, 2014

BANGLADESH JOURNAL OF RADIOLOGY AND IMAGING 2014; VOL. 22(2): 53

EDITORIAL

According to Journal of the American Medical

Informatics Association Volume 1 Number 5 Sep /Oct 1994 the summary of the Benefits of the PictureArchiving and Communication System (PACS) are

• Category 1- benefits to the diagnostician

- Improved access to current patient records.

- Improved access to patient history records

- File integrity and speed of retrieval

- Better diagnosis

• Category 2- benefits to the referring physician

- Better patient management/earlierintervention

- Better patient outcome in reduced lengthof stay

- Reduced legal costs due to maladminis-tration claims based on loss of films, lackof patient history, etc.

• Category 3-benefits to the patient

- Reduced radiation exposure from x-rayequipment

- Shorter examination times

- Reduced radiation exposure as a result ofless need for retakes of images

- Reduced patient inconvenience inattending hospitals for examinations andreexaminations

- Reduced chance of adverse reaction tocontrast agents

• Category 4- benefits to the hospital

- Better communication with physicians

- Better hospital administration & bettertraining of radiology and other studentsthrough access to on-line image files andto digital teaching files

- Greater staff retention

The traditional film based system existing inBangladesh is facing array of shortcomings anddrawbacks such as high turnaround time, film loss

PACS (Picture archiving and Communication System)

... Continuation from previous issue

and high cost of generation, storage and transport:

as is noted in many countries. PACS have the

potential for immense rationalization of operations

in radiology and hence for the improvement of

health care, as well as the return of investments.The combined PACS-RIS-HIS web browsertechnology can access images through a short termPACS server and can display them even onordinary desktop personal computers. This hasprovided a cheap and easy means of reviewingimages with much ease. Moreover, the facility ofremote and multiple accesses of all digital imagesand image manipulation, cases can be sharedthrough e-mail or other means and can be usedfor teaching also.

In spite of huge benefits, the practical applicationof such a system is indeed not straight forward fora developing nation with limited resources. Thepractical implications of the lack of basictechnology, network infrastructure, qualifiedpersonnel, strategy and legal backing need to beaddressed very carefully. Consideration must begiven to local issues, improvement of basictechnology, organizational factors, staffing, humanaspects and attitude, policy and legislation forproper implementation of the system

We can confidently assume the near future, wherethe ongoing film based systems inevitably will becomeobsolete in such a way that one may search the “last

remaining film” in the “dark room museum”.

Mariyam Sultana

Medical Officer

Department of Radiology & Imaging,

Dhaka Medical College Hospital

References :

1. Shawn H. Becker, Ronald L. Arenson . Costs andBenefits of Picture Archiving and CommunicationSystems. Journal of the American MedicalInformatics Association. 1994; 1:5.

BANGLADESH JOURNAL OF RADIOLOGY AND IMAGING 2014; VOL. 22(2): 55-59

ORIGINAL ARTICLES

Abstract

Objective: This study was performed to compare

superior mesenteric Arterial Resistive Index in

diabetic patients with pancreatic calculi before and

after meal and those of control subjects. Method:

This cross sectional study was attempted on 80

subjects aged 16 to 36 in the Department of

Radiology & Imaging, BIRDEM from January

2012 to December 2013. Out of them 38 diabetic

patients with pancreatic calculi were considered

as case group and 42 healthy subjects as control

group with compatible age, sex and weight. To

eliminate the bias Doppler study was performed

first by the investigator herself and subsequently

confirmed by a senior radiologist in the

Department of Radiology & Imaging, BIRDEM.

Doppler findings were recorded from superior

mesenteric artery. Result: In this study the mean

fasting RI was 0.85 with standard deviation (SD)

±0.02 and their range was from 0.89 to 0.82 in

control group. In case group the mean RI was 0.79

with standard deviation (SD) ±0.03 and their range

was from 0.74 to 0.85. The fasting mean RI

difference were found statistically significant

(p<0.05) between control group and case group in

unpaired t-test.The mean postprandial RI was 0.72

with standard deviation (SD) ±0.04 and their range

was from 0.80 to 0.66 in control group. In case

group the mean RI was 0.74 with standard

Comparison of Superior Mesenteric Arterial

Index in Diabetic Patients with Pancreatic

Calculi Before and After Meal and Those of

Control SubjectsFAHMIDA YESHMINE1, MAHBUBA HUSSAIN2, SHARMISTHA DEY3, MD TOWHIDUR RAHMAN3,

ABU SALEH MOHIUDDIN4, REHNUMA JAHAN5, KHABIR AHMED6, SHAFIUL AZAM7

1. Assistant Professor, Dept. of Radiology & Imaging, BIRDEM, Dhaka, 2. Registrar, Dept. of Radiology & Imaging,

BIRDEM, Dhaka, 3. Assistant Professor, Dept. of Radiology & Imaging, BIRDEM, Dhaka, 4. Professor and head of

the Dept. of Radiology & Imaging, BIRDEM, 5. Consultant, Department of Obs & Gynae, Square Hospital Limited.

6. Senior Consultant, Department of Radiology & Imaging, Noakhali 250 Bedded General Hospital. 7. SeniorConsultant, Department of Radiology & Imaging, Narayanganj 300 Bedded General Hospital.

deviation (SD) ± 0.049 and their range was from

0.84 to 0.68. The postprandial mean RI difference

were statistically significant (p<0.05) between

control and case group in unpaired t-test.

Conclusion: In this study it can be concluded

that there is statistically significant difference in

reduction of Superior Mesenteric Arterial

Resistive Index before and after meal evaluated

by Duplex Color Doppler Ultrasound in diabetic

patients with pancreatic calculi compared to healthy

subjects.

Key word: Diabetic patient with pancreatic calculi

- Duplex Color Doppler Ultrasound - Superior

mesenteric artery.

Introduction

In developing countries peculiar forms of diabetes

associated with under nutrition have been reported

since the beginning of the century. Conflicting

criteria and various clinical presentation of the

disease lead to confusion in proper characterization

of these forms of diabetes.

According to WHO and American Diabetic

Association (ADA) classification (1985) etiologically,

Diabetes Mellitus is of five types: 1. Insulin

Dependent Diabetes Mellitus 2.Non-Insulin

Dependent Diabetes Mellitus 3. Malnutrition

Related Diabetes Mellitus(MRDM) 4. Gestational

Diabetes Mellitus and 5. Diabetes associated with

other condition and syndrome.1

MRDM has again been subdivided in two groups.

1) Fibro-calcific Pancreatic Diabetes (FCPD) and

2) Protein Deficient Diabetes Mellitus (PDDM).

Pancreatic Calculi with Diabetes is also known as

Fibro-calcific Pancreatic Diabetes (FCPD). In 1997,

WHO and ADA expressed that FCPD is secondary

diabetes. Pancreatic calculi develop from calcium

deposits as result of chronic pancreatitis and can

block the pancreatic duct which connects the

pancreas with small intestine. The flow of digestive

enzymes released by pancreas cannot pass into the

intestine and its secrated hormones that regulate

blood sugar can be affected.

Most of the patients are in age of 10-30 years when

the diagnosis is made but FCPD may occur in

infants, children and elderly.2,3 The clinical picture

of FCPD consists of the four cardinal features ;

abdominal pain , pancreatic calculi , maldigestion

leading to steatorrhoea and diabetes.

The diagnosis of FCPD is usually made during

investigations for pain in the abdomen. Test of

pancreatic structure includes: Ultrasound,

Endoscopic Ultrasonography, Computed

Tomography, Endoscopic Retrograde Cholangio-

pancreatography (ERCP) and Magnetic Resonance

Cholangiopancreatography (MRCP).4

The diagnosis is based on combination of clinical

evaluation and imaging studies. In advanced

disease, a plain film of abdomen or a computerized

tomography may show pancreatic calcification and

establish the diagnosis. In early case demonstration

of ductal changes through ERCP or MRCP will

establish the diagnosis. Pancreatic function tests

are indeed the most sensitive test to detect the

earliest changes in exocrine pancreas but they may

be abnormal in any causes of pancreatic inefficiency

e.g. cystic fibrosis and necessarily chronic

pancreatitis. Many approaches have been used to

determine the etiology of pancreatic disease and

have strengths and limitations. Histology remains

the gold standard for defining pathology but this

approach is limited by danger of pancreatic biopsy.

In a study by Anderson it was found that an

ultrasound scanning combined with the pulsed

doppler technique can non-invasively monitor the

alterations in blood flow velocity.5 Applied to the

superior mesenteric artery (SMA), the method

confirms that blood flow in this vessel increases in

response to a meal.

Hornum et al observed that blood flow in SMA

increases after meal due to vasoactive effect of the

decomposed food but in exocrine pancreatic

insufficiency the digestion of food is compromised6.

Patients with end stage chronic pancreatitis are

characterized by mal-digestion due to exocrine

pancreatic insufficiency; the reduced intra luminal

food digestion is mirrored in the mesenteric blood

flow. These patients would show less postprandial

increased in mesenteric blood flow. The Resistive

Index (RI) in the SMA was determined before and

after meal. The RI reflects the downstream

circulatory resistance, giving a precise description

of hyperaemia. Patients with exocrine pancreatic

insufficiency unexpectedly had lower fasting RI

than control, 0.818 vs. 0.851 respectively.

Postprandial there was significantly less decrease

in RI (less increase in flow) in patients with

exocrine pancreatic insufficiency than control, 0.055

vs. 0.099. There was a significant trend for a less

pronounced postprandial disease in RI with more

impaired pancreatic function. The postprandial shift

in Doppler velocity pattern might be used in the

diagnosis and monitoring exocrine pancreatic

insufficiency.

The diagnosis of extent and nature of blood flow

abnormality is important in the evaluation and

management of FCPD patients. Intra arterial digital

subtraction angiography has been considered the

gold standard in diagnostic imaging for the

evaluation of SMA but it is invasive and expensive7.

Ultrasound is now both competitive and

complementary to angiography for many arterial

Bangladesh Journal of Radiology and Imaging Vol. 22(2): July 2014

56

investigations even when the circulation is

seriously compromised8.

Material & Method

This cross sectional study was carried out in the

Dept. of Radiology & Imaging, BIRDEM from

January 2012 to December 2012. This study

included 38 diabetic patients with pancreatic

calculi, sent from Dept. of Gastroenterology,

BIRDEM, clinically, biochemically & radiologically

confirmed as case group and 42 healthy patients

as control group. The equipment used was

Siemens Sonoline machine with 3.5 MHz

transducer. Gray scale imaging was performed

first to obtain an overview anatomy of pancreas

and superior mesenteric artery. Then Doppler

study was done.

Prior to the commencement of this study the

research protocol was approved by the Ethical

Committee. The objective of the study had been

discussed in details with the case & control group

before they decided to enroll themselves in the

study. It was assumed that all information and

records would be kept confidential and the

procedure would be helpful for both the surgeon

and the patient in making rational approach in

the case management. Color Doppler study and

spectral analysis of superior mesenteric artery

were performed first by the investigator herself

and subsequently confirmed by a radiologist of the

department separately to eliminate biased

judgment.

Data were collected from primary source starting

from the clinical history, Duplex color Doppler

findings, and spectral analysis by predesigned

structured data collection sheets. Statistical

analyses of the results were done by computer

software device statistical packages for social

scientists (SPSS). The results were presented in

tables. For significant difference unpaired t-test

and Chi square tests were used. A ‘p’ value <0.05

was considered significant.

Result:

Total 80 subjects were included in this study

according to the criteria mentioned in material

and method. The findings derived from data

analysis are given below.

Table I

RI of the study subjects (Control = 42, Case = 38)

Subjects Control Case Statistical Analysis

Fasting [ Mean ± SD] 0.85 ± 0.02 0.79 ± 0.03 p = 0.003

Range (Max. – Min.) 0.07(0.89 - 0.82) 0.11 (0.85–0.74)

Postprandial [ Mean ± SD] 0.72 ± 0.04 0.74± 0.049 p = 0.046

Range (Max. – Min.) 0.26 (0.80 – 0.66) 0.16(0.84–0.68)

P value of <0.05was considered significant

Table II

Decrease in RI of the study subjects before and after meal (Control = 42, Case = 38)

Subjects Mean ± SD Range (Max. – Min.) Statistical Analysis

Control 0.10 ± 0.05 0.11(0.16-0.05) p = 0.0275

Case 0.04 ± 0.047 0.06 (0.11-0.05) p = 0.0275

p value of <0.05was considered significant

Comparison of Superior Mesenteric Arterial Index in Diabetic Patients Fahmida Yeshmin et al

57

Discussion

This cross sectional study was done to compare

the Resistivity Index (RI) of Superior Mesenteric

Artery (SMA) in clinically diagnosed patients of

Pancreatic Calculi with Diabetes and control

healthy patients in order to observe the decrease

of blood flow in superior mesenteric artery after

meal in both groups, in the Dept. of Radiology &

Imaging, BIRDEM. For this purpose 38 cases and

42 controls were enrolled as subjects. Duplex Color

Doppler sonography of SMA was carried out in both

groups to measure the Resistivity Index (RI).

Observations of the study were analyzed to

compare the RI values of SMA of case and control

group.

RI was used to characterize downstream

circulatory resistance in the SMA. It was calculated

from two Doppler shift frequencies measured in

the same image and was independent of the angle

of insonation. Regarding decrease of RI, it was

observed that RI decreased about 0.01 with a

standard deviation (SD) ±0.05 and their range was

from 0.16 to 0.05 in control group whereas in case

group, RI decreased 0.04 with a standard deviation

(SD) ±0.047 and their range was from 0.11 to -0.05.

Unpaired t-test revealed that the difference in

decrease of RI was found statistically significant

(p<0.05) between control and case group. The mean

fasting RI was 0.85 with standard deviation (SD)

0.02 and their range was from 0.89 to 0.82 in

control group which is in agreement with results

from other studies conducted by other authors also6,9,10. In case group the mean RI was 0.79 and the

fasting RI was from 0.74 to 0.85. The fasting mean

RI difference was found statistically significant

(p<0.05) between control and case group. This result

is very much similar to the study conducted by

Hornum et al where the fasting RI in the SMA

was significantly lower than controls, 0.82 in both

groups. This suggests a more dilated vascular bed

peripherally in the SMA territory in the fasting

state in patients with chronic pancreatitis. This

has not been previously reported, and further

studies are needed to confirm this incidental

observation. It could be speculated that in chronic

pancreatitis the mechanisms that regulate the flow

in the SMA are adapted to a weaker stimulus from

the digested food components. If other studies

confirm this observation, it might be considered

worthwhile to determine RI in the SMA routinely

in all fasting upper abdominal studies, or at least

in studies without an obvious diagnosis. An

unusually low RI would suggest undetected

abdominal pathology like inflammatory bowel

disease or chronic pancreatitis. After the meal RI

decreased less (downstream resistance decreased

less) in patients with pancreatic calculi compared

to patients with preserved exocrine function or to

healthy controls. The mean postprandial RI was

0.72 compared to case group where the mean RI

was 0.74. The fasting RI difference was found

statistically significant (p<0.05) between control

and case group.

The study confirms the hypothesis of a reduced

postprandial increase in SMA flow in patients with

exocrine pancreatic insufficiency. Further studies

are needed to evaluate whether the meal induced

shift in RI in the SMA can be used in the diagnosis

and monitoring of chronic pancreatitis.

Conclusion:

From the finding of the present work it is

conceivable that pancreatic calculi affects the

mesenteric arterial flow which can be detected by

non invasive Duplex Color Doppler imaging which

may help in proper patient management . However

further study can be carried out by including large

number of study subjects along with CT/MRangiography.

References

1. WHO study group report on DiabetesMellitus. WHO Technical Report series no727, Geneva WHO 1985.

2. Mohan V, Ramachandran A, BishwanathanM 1989, “Childhood Onset FIbrocalculousPancreatic Disease”, Assoc Physician India,vol. 37,pp. 342-345.

3. Mohan V, Suresh S, Suresh et al 1989,”Fibrocalculous Pancreatic Diabetes inElderly”, Assoc Physician India, vol. 37, pp342-345.

4. Mohan V, Nagalotimath SJ, Yajnik CS et al1998, “Fibrocalcific Pancreatic Diabetes”,

Metabe, vol. 14, pp. 153-170.

Bangladesh Journal of Radiology and Imaging Vol. 22(2): July 2014

58

5. Anderson TC, Pederson JF, Nordentoft T,

Olsen O 1999, “Fat and mesenteric blood

flow”, Scand J Gastroenterol , vol. 34, pp. 894-

897.

6. Hornum M, Larsen S, Olsen O, Pedersen J F

2006, “Duplex Ultrasound of the SuperiorMesenteric Artery in Chronic Pancreatitis”,

The British Journal of Radiology, vol. 79, pp.

804-807.

7. Abnay A, Bedi VS, Indrajit IK, Souza JD 2003,“Evaluation and Management of PeripheralArterial Disease in Type 2 Diabetes Mellitus”,

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59

BANGLADESH JOURNAL OF RADIOLOGY AND IMAGING 2014; VOL. 22(2): 60-67

Correlation between Volume of Hippocampal

Formation & Age, Sex of Adult Subjects with

Normal MRI of BrainMD TOWRIT REZA1, MISBAH UDDIN AHMED2, SHAHRYAR NABI3, MD SHAHIDUL ISLAM3,

KHADIJA BEGUM4, MOHAMMED MAHBUB ULLAH5, AKM GOLAM KABIR6 , KHABIR AHMED7,

SUSHANTA KUMAR SARKAR8

1. Consultant Radiology (CC), Faridpur Medical College Hospital, Faridpur, 2. Associate Professor, Department of

Radiology & Imaging, Mymensingh Medical College & Hospital, Mymensingh, 3. Assistant Professor, Department

of Radiology & Imaging, Dhaka Medical College & Hospital, Dhaka, 4. Medical Officer, Department of Radiology &

Imaging, Mymensingh Medical College & Hospital, Mymensingh, 5. Radiologist, National Institute of Cardiovascular

Diseases and Hospital (NICVD) Dhaka. 6. Assistant professor, Department of Radiology & Imaging, National

Institute of Neuroscience, Dhaka, 7. Senior consultant, Department of Radiology & Imaging, Noakhali 250 beddedGeneral Hospital, 8. Assistant Professor, Department of Radiology & Imaging, Shaheed Tajuddin Ahmad Medical

College, Gazipur, Dhaka.

Abstract:

Objective: To find out the correlation between MRI

measured volume of hippocampal formation with

age, sex of adult individuals.

Methodology: This descriptive study was carried

out on 47 healthy adult subjects referred to the

Department of Radiology and Imaging of National

institute of Ophthalmology (NIO) for evaluation of

brain with different complaints during July 2009

to June 2011. Detailed history, clinical

examinations with special attention to nervous

system and volume of hippocampal formation were

measured by MRI. Unpaired t-test and Pearson’s

correlation coefficient were used to assess the

correlation between hippocampal formation with

age by using the Statistical Package for Social

Sciences version 20.0 for Windows (SPSS Inc.,

Chicago, Illinois, USA).

Result: Majority (27.7%) the subjects were in 4th

decade and the mean age was 37.5±12.5 years. Male

female ratio was 1.5:1. The mean volume was

3984±164mm3 with range from 3406 to 4227 mm3

in the whole study subjects. A significant negative

Pearson’s correlation coefficient (r= -0.566; p=0.002)

was observed between volume of hippocampus

formation with age in male subject, but no

correlation (r =0.204; p=.237) was found in female

subject. The mean (±SD) volume of hippocampus

formation was 4182±31.1 mm3 in 2nd decade and

3926±141.1 mm3 in 6th decade and onward in male

subjects, which was significantly (p<0.05) less in

older age group in male subjects. Similarly, in

female subjects, the mean (±SD) volume of

hippocampus formation was 3843±68.59 mm3 in 2nd

decade and 3963 mm3 in 6th decade and onward in

female subjects. The mean volume of hippocampus

formation was almost similar in early age and older

age in female subjects.

Conclusion: There is an association between

hippocampal formation with age in male i.e. the

volume decline with age increased in male appeared

to be linear but no correlation observed in female

subjects.

Key Word: Hippocampal formation, MRI brain,

volume change, temporal lobe.

Introduction

The hippocampal formation is a compound

structure in the medial temporal lobe of the brain.

There is currently no consensus concerning which

brain regions are encompassed by the term, with

some authors defining it as the dentate gyrus, the

hippocampus proper and the subiculum1 and others

including also the pre-subiculum, para-subiculum

and entorhinal cortex2. The hippocampal formation

is thought to play a role in memory and control ofattention. The neural layout and pathways within

the hippocampal formation are similar in all

mammals.

Correlation between Volume of Hippocampal Formation & Age, Sex of Adult Subjects Md Towrit Reza et al

61

Magnetic Resonance Imaging (MRI) provides a non-

invasive method for investigating brain

morphology. Within the medial temporal lobe,

special attention has been paid to the hippocampus

(HC) and amygdala (AG) because of their role inmemory, depression, emotion and learning3.Volume changes in these areas have been observedin conjunction with certain disease states, such astemporal lobe epilepsy (TLE), Alzheimer’sdementia, mild cognitive impairment,schizophrenia, post-traumatic stress disorder anddepression. Its volume, morphology, innerstructure and functions are of scientific and clinicalinterest4.

Magnetic resonance imaging (MRI) has become themethod of choice for the examination of

macroscopic neuro-anatomy in vivo due to excellent

levels of image resolution and in between tissue

contrasts. MRI is a widely employed tool in neuro-

radiological workup regarding changes in brain

anatomy, volumes and cerebral function including

the hippocampus5. A wide variety of software

packages are available for viewing and appraisingMR images, for reformatting the images in threedimensions so as to obtain sections with a

particular orientation through the body and for

making both simple and more sophisticated

measurements of regions of interest, compartments

and individual structures.

Aging has also been shown to result in gray mattervolume loss of the overall brain, including the HCwith regard to gender specificity, results suggestlarger shrinkage for men of brain gray matter. Asignificant negative correlation with age for bothleft and right HC was found in men but not inwomen. The volume decline in men appeared tobe linear, starting at the beginning of the thirdlife decade and approximating 1.5% per annum. Itwas shown that changes with age occurred mostly

in the head and tail of the HC. There is also

significant difference between male and female

hippocampus. This finding underscores the need

to include socio-demographic variables in functional

and anatomical MRI designs3.

This study is designed to find out the correlation

between MRI measured volumes of hippocampal

formation with that of age & sex of an adult

individual.

Materials and Methods:

This descriptive study was carried out on 47 adult

subjects aged from 18-69 years referred to the

Department of Radiology and Imaging of National

institute of ophthalmology (NIO) for evaluation of

brain with different complaints during July 2009

to June 2011. Adult subjects without known

temporal lobe pathology and both sexes were

included in this study. Adult subjects who had MRI

detected pathology with special attention to

temporal lobe was excluded from the study. Prior

to the commencement of this study, the research

protocol was approved by the thesis committee

(Local Ethical Committee). The aims and objective

of the study along with its procedure, alternative

diagnostic methods, risk and benefits were

explained to the subjects in easily understandable

local language and then informed consent were

taken from each subjects. It was assured that all

records would be kept confidential and the

procedure would be helpful for both the physician

and patients in making rational approach regarding

management of the case. At first all subjects were

evaluated with detailed history and clinical

examinations with special attention to nervous

system. Their MRI findings were evaluated and

volumes of hippocampal formation were measured

among these cases.

Procedure of MRI Measurement of Volume

of Hippocampal Formation:

MR image acquisition. MRI scans were obtainedusing a Siemens Magnetom Avanto 1.5T systemwith a standard radio frequency head coil (NationalInstitute of ophthalmology). T1-weighted imaging

offers the greatest clarity between grey matter,

white matter and CSF, and is therefore used for

quantitative MRI studies of brain morphology,

particularly of individual brain structures. For the

purpose of this study, only the FLASH 3D scanswere used. These volumes were acquired using athree-dimensional (3-D) spoiled gradient echoacquisition with sagittal volume excitation. The

square field of view for the sagittal images was

220 mm superior-inferior by 220 mm anterior-

posterior.

Assessment of HC volume. In short, the following

procedures for delineation of HC were used. The

Bangladesh Journal of Radiology and Imaging Vol. 22(2): July 2014

62

most posterior part of the HC was defined as the

first appearance of ovoid mass of gray matterinferio-medial to the trigone of the lateral ventricle(TLV). The lateral border of the HC at this pointwas the TLV, whereas medially, the border of theHC was identified by white matter. Furtheranterior, an arbitrary border was defined for thesuperior and medial border of the HC, todifferentiate HC gray matter from the gray matterof the Andreas Retzius gyrus, the fasciolar gyrus,and the crus of the fornix. This border was definedby drawing a vertical line from the medial end ofthe TLV inferiorly to the para-hippocampal gyrusand a horizontal line from the superior border ofthe quadro-geminal cistern to the TLV. The inferiorborder of the HC at this point was again identifiedby white matter.

Manual techniques of HC volume

measurement. Tracing methods used to tracethe HC using a mouse driven cursor throughout adefined number of MR sections. The transect areas,determined by pixel counting within the tracedregion, are summed and multiplied by the distancebetween the consecutive sections traced toestimate the volume. Whilst tracing methodsrepresent the most commonly used tool to estimatebrain structure volume on MR images.

After collecting all the necessary information

regarding the study, data was collected in a pre-

designed structured data collection sheets. Data

was collected from clinical history and Magnetic

Resonance Imaging (MRI). Statistical analyses

were carried out by using the Statistical Package

for Social Sciences version 20.0 for Windows (SPSS

Inc., Chicago, Illinois, USA). The mean values were

calculated for continuous variables. The

quantitative observations were indicated by

frequencies, percentages and bar diagram.

Unpaired t-test was used to analyze the continuous

variables, shown with mean and standard

deviation. The Pearson’s correlation coefficient was

used to assess the correlation between hippocampal

formations with age and presented in graph. A “p”

value <0.05 was considered as significant.

Results

The mean age was 37.5±12.5 years varied from 18to 69 years and 13(27.7%) the subjects were in 4th

decade followed by 12(25.5%) were in 3rd decade,10(21.3%) were in 5th decade, 6(12.8%) were in 6th

decade, 4(8.5%) were in 2nd decade and the lowestnumber 2(4.3%) were observed in 7th decade. Outof 47 individual, 28(59.6%) and 19(40.4%) weremale and female subjects respectively. Male femaleratio was 1.5:1.

The volume of hippocampal formation wasmeasured in mm3 and they were divided into twogroups and found that most (53.2%) of the volumeof hippocampal formation were <4000 mm3 and

rest 22(46.8%) were ≥4000 mm3 and the mean

volume was 3984.19±164 mm3 with range from

3406 to 4227 mm3.

Correlation between volume of hippocampal

formation (mm3) in male subjects and age (n=28).

Fig 1: Scatter diagram showing significant negative

Pearson’s correlation coefficient (r=-0.566; p<0.05)

between volume of hippocampal formation with age

in male subject.

Correlation between volume of hippocampal

formation (mm3) in female subjects and age (n=19).

Fig.-2: Scatter diagram showing the no significant

Pearson’s correlation coefficient (r=0.204;p>0.05)

between volume of hippocampal formation with age

in female subjects.

Correlation between Volume of Hippocampal Formation & Age, Sex of Adult Subjects Md Towrit Reza et al

63

Discussion

This study was done to assess the role of MRI in

volume measurement of hippocampal formation

and to find out the correlation between MRI

measured volume of hippocampal formation with

age and sex of an adult individual. Most (27.7%)

the subjects were in 4th decade and the mean age

was 37.5±12.5 years with range from 18 to 69 years.

In this present study it was observed that 59.6%

were male and 40.4% were female subjects, which

closely resembled with Sullivan6 study, where the

authors enrolled 21 to 70 years healthy subjects.

Similarly, other authors have observed almost

similar age range in adult subjects, which support

the present study7,8,9,10. In a study Jonsson11

showed that male female ratio was almost 2:1,

which is consistent with the current study. Female

predominant studies were observed by some

authors12,13,14,15,16. Free et al17 observed the

volume of hippocampus formation range from 2240

to 3480 mm3, which is less with the current study,

this may be due to geographical variations, racial

influences, ethnic differences, genetic causes and

different lifestyle may have significant impacts on

hippocampus formation.

Table I

Distribution of the male and female subjects according to their different age group and respective MRI

measured mean hippocampal volume

Age n=28 Volume (mm3) in male subjects n=19 Volume (mm3) in female subjects

(years) n Mean±SD Min-Max n Mean±SD Min-Max

Up to 20 2 4182±31.1 4160-4204 2 3843±68.59 3794-3891

21 – 30 6 4105±123.5 3870-4227 6 3809±240.7 3406-4109

31 – 40 6 4040±152 3838-4225 7 4021±36.4 3951-4055

41 – 50 7 4068±150.1 3735-4161 3 4003±48.22 3976-4072

51 – 60 5 4006±44.45 3982-4085 1 3963 3963-3963

>60 2 3727±12.02 3718-3735 -

Total 28 4023.9±155.7 3718-4227 19 3926.7±162.1 3406-4109

The mean (±SD) volume of hippocampal formation was 4182±31.1 mm3 in 2nd decade and 3926±141.1

mm3 in 6th decade and onward and the difference was statistically significant (p<0.05) in male subjects.

In female subjects it was 3843±68.59 mm3 in 2nd decade and on the other hand one patient was found in

6th decade and her volume of hippocampal formation was 3963mm3.

Diagrammatic picture of hippo-

campus formationShowing MR measured pixels(317 Pixels) of hippocampulformation of a 38 years old malesubject

Showing MR measured pixels(270 Pixels) of hippocampulformation of a 23 years old malesubject

Bangladesh Journal of Radiology and Imaging Vol. 22(2): July 2014

64

A significant (p=0.002) negative correlation (r = -

0.566) was observed between volume of

hippocampus formation with age in male subject,

but no correlation (r =0.204; p=.237) was found in

female subject. Sullivan et al6 mentioned in their

study that hippocampal volumes significantly

correlated with age, which decreased significantly

with each age (p<0.01). Similarly, Starkman et al18

showed hippocampal formations (HF) volume

negatively correlated with age, which suggests an

association between reduced HF with age increase

in male subjects. In another study Pruessner et

al3 found a significant negative correlation with

age for both left and right HC in men (r=-0.47 and

-0.44, respectively) but not in women (r = 0.01 and

0.02, respectively). Almost similar relation also wasobtained by Free et al17 which closely resembledthe present study.

In male subjects the volume of hippocampus

formation showed a significant (p<0.05) decline with

increased age, however the mean volume of

hippocampus formation was almost similar in early

age and older age in female subjects, no significant

(p>0.05) difference was observed in this study. In

a study, Walhovd et al19 reported that the mean

volumes of hippocampal per decade for the total

sample and showed the estimated percentage of

change in each structure per decade based on the

raw volumes. The mean volume of hippocampal

was in a decline with age increase per decade in

male subject but no relation was found in female

subject. Study results by Pruessner et al3 suggest

a significant gender difference with regard to HCvolume decline with aging in early adulthood inadult subjects.

However, although men showed a consistent

decline between the third and fifth decade of life

with regard to hippocampal volume, women in this

age range remained almost constant. The

calculated volume decline in men corresponds to

an annual loss of 1.5%. In another study, Jernigan

et al 20 showed first, that the age-related

hippocampal formation volume decline begins early

in adulthood. Although previous studies reported

a decline of brain volume beginning at the end of

the second life decade, it was so far unknown

whether this would also be true for structures of

the medial temporal lobe or, more specifically, the

HC. Jack et al21 reported a volume decline of the

hippocampal formation with an annual rate of 1.5%

for both men and women in a group of healthy

elderly ranging from 70 to 89 years. Coffey et al22

showed a smaller volume loss of 0.3% per annum

for the amygdaloid– hippocampal complex in

healthy adult volunteers and Kaye et al23 described

a volume decline of 2.1% in the hippocampal

formation per year in healthy subjects 84 years

and older.

The findings of the present study suggest that the

age-related hippocampal formation volume decline

in men starts at the beginning of the third life

decade. Second, the hippocampal formation volume

decline with age is gender specific. Earlier studies

suggested gender differences with regard to age

related volume decline of brain structures but not

the HC. Interestingly, Gur et al24 reported an

almost identical correlation for volume decline of

hippocampal formation volume for men in the same

age range; for women, they reported a smaller yet

significant decline of total hippocampal formation

volume as well. Although some studies 25,26

reported stronger temporal lobe volume decline

with age in men than in women, others found no

gender differences27 or reported greater temporal

lobe atrophy in women than in men28.

One study, Golomb et al29 reported that men havemore atrophy in the HC assessed volume declineon a four-point scale. Also, the authors did notdiscuss the age onset of the hippocampal formationvolume decline. The present study extends

previous findings by showing that the hippocampal

formation volume is susceptible to gender-specific

age-related decline starting in early adulthood and

it further allows estimation of the annual volume

loss of this structure. Third, morphometric changes

of the hippocampal formation volume with age

seem to be located mostly in the head and tail of

the hippocampal formation volume, as revealed

by the voxel-based regressional analysis. This is

the first study to show region specificity of age-

related processes within the hippocampal

formation volume in humans. Jack et al21 showed

that the HC volume head might be most susceptible

to the influences of aging.

Correlation between Volume of Hippocampal Formation & Age, Sex of Adult Subjects Md Towrit Reza et al

65

In the man, shrinkage of the hippocampal volume

with an expansion of the adjacent ventricles would

explain the observed results. Other possibilities

include pathological or inflammatory processes

within the cells of the HC, which have been found

to cause a signal decrease in T1 images30,31.

Vymazal et al32 mentioned in their study that

changes in the iron content of cells can have a

significant impact on the MR signal, and these

might be age-related.

However, the changes within the hippocampal

volume were observed only at the border and not

throughout the structure, favoring a volume

decline as a possible explanation. In the women,

the signal-intensity increase could reflect an

increase in white matter, which is supported by

the notion that the increase occurred in regions

where white matter bands border the hippocampus.

In fact, most of the studies22,33 investigating HC

volume changes with age have chosen elderly

populations. Finally, it needs to be addressed which

functional consequences this finding might have.

However, to test for possible gender differences in

hippocampal volume morphology and its

association with memory function, gender needs

to be included as an independent variable in the

respective study designs.

Conclusion

From the findings in this study in can be concluded

that there is an association between hippocampal

formation with age in male i.e. the volume decline

with age increased in male appeared to be linear

but no correlation observed in female subjects.

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Bangladesh Journal of Radiology and Imaging Vol. 22(2): July 2014

67

Abstract:

Objective: The objective of the study was to see

the diagnostic performance of MRI in the evaluation

of tuberculous spondylitis.

Methodology: This cross sectional study was

carried out among 40 patients in the Department

of Radiology & imaging, Dhaka Medical College

Hospital (DMCH) in Collaboration with Department

of Neurosurgery and Pathology, DMCH during the

period of 1st July 2011 to 30th June 2013. Clinically

suspected patients of tuberculous spondylitis who

was referred for MRI scan of spine were purposively

selected. MRI diagnosis was compared to

histopathological diagnosis.

Result: The validity of MRI scan in the evaluation

of tuberculous spondylitis was shown by sensitivity,

specificity, accuracy, positive and negative

predictive value which were 92.86% , 83.33% , 90%,

92.86% , 83.33% respectively.

Conclusion: MRI scan can be regarded as a good

imaging modality for the diagnosis of tuberculous

spondylitis.

Introduction:

Tuberculosis is one of the most contagious diseases

causing morbidity and mortality¹. Tuberculous

spondylitis is an infection involving one or moreof the components of the spine, namely thevertebral body, intervertebral disc and ligaments,para-vertebral soft tissues, and the epidural space.The causative organism belongs to one of the

different strains of Mycobacterium tuberculosis².

In the developing countries, the disease commonly

affects children and young adults and tends to be

more aggressive in extent and abscess formation.

Consequently, neurologic complications and spinal

deformities are seen frequently. In the developed

Performance of Magnetic Resonance Imaging in

the Diagnosis of Tuberculous SpondylitisNAZMA FARZANA CHOWDHURY1, MD MIZANUR RAHMAN2, ROBINDRANATH SARKER3, MAJ

MAKSUDA KHANOM4, GOPAL CHANDRA SAHA5, AKANDA FAZLE RABBI6, MD ANISUR RAHMAN7

1. Radiologist, STS Life Care Centre,. 2. Professor and Head, Department of Radiology and Imaging, DMC.3. Associate Professor, DMC. 4. Classified Radiologist, CMH, Dhaka. 5. Radiologist, Narsinghdi District Hospital6. Associate Professor, DMC, 7. Assistant Professor, Department of Radiology and Imaging, Rajshahi MedicalCollege Hospital.

countries, musculoskeletal tuberculosis is

uncommon, but its incidence is reported to be

greater in older individuals³.

Tuberculous spondylitis is typically more indolent

than pyogenic osteomyelitis. Untreated patients

develop progressive vertebral collapse with

anterior wedging and gibbus formation4.The

kyphotic deformity is caused by collapse in the

anterior spine. A cold abscess can occur if the

infection extends to adjacent ligaments and soft

tissues5. Paraplegia may be a result of spinal cord

compression from liquid or casseous pus,

inflammatory granulation tissue of active disease

or kyphotic deformity in the late stage of disease.

Therefore, early diagnosis and establishment of

treatment are necessary for avoiding this long term

disability6.

Magnetic resonance (MR) imaging is effective in

the early diagnosis of tuberculous spondylitis. Italso detects lesions, which may not be apparenton plain radiograph7. High contrast resolution,direct multi-planar imaging, usefulness indetecting marrow infiltration, and ease by whichintra-dural disease can be assessed are definite

advantages. On MR images, vertebral intra-osseous

abscesses, para-spinal soft tissue abscesses that

extended beyond the confines of disc collapse,

spinal deformity (gibbus), skip lesions

encroachment on spinal canal and nerve roots,

and involvement of the posterior elements are

all readily detectable. Enhanced MR studies are

particularly useful for characterizing tuberculous

spondylitis. Rim enhancement around intra-

osseous and para-spinal soft tissue abscess had not

been demonstrated in other spinal infection8. The

two most reliable MRI findings suggesting

tuberculous spondylitis were thin and smooth

BANGLADESH JOURNAL OF RADIOLOGY AND IMAGING 2014; VOL. 22(2): 68-73

enhancement of the abscess wall and welldefined para-spinal abnormal signal9. The studywas designed to establish MRI as a usefulmodality for diagnosis and evaluation oftuberculous spondylitis .

Materials and Methods:

This cross sectional study was carried out on 40patients in the Department of Radiology andImaging, DMCH in collaboration withDepartment of Neurosurgery and Pathology,DMCH, during the period of 1st July 2011 to 30th

June 2013. Consecutive cases were collectedpurposively who fulfilled the inclusion criteria. Theinclusion criteria were clinically suspected patientsof tuberculous spondylitis. Exclusion criteria were(a) Patients who refused to undergo operativetreatment (b) Non-availability of histopathogicalreport.

Prior to commencement of this study, theresearch protocol was approved by the ethicalcommittee of DMC. Informed consent was takenfrom each patient. Data was collected by pre-designed data collection sheet. All other necessarydata were collected from history sheet andinvestigation papers. A 0.3 Tesla open MRImachine (AIRIS – II - HITACHI) was used. Imageswere taken of T1WI, T2WI and T1 contrastsequence in sagittal, axial and coronal plane.

Pre and post contrast MRI scans were evaluatedby the researcher and a senior radiologist. Patientswho underwent operation, histo-pathologicalreports were collected. Out of 43 cases, 3 wereexcluded from the study due to unavailability ofhistopathological report and refused to dooperation. Finally MRI findings of 40 patients werecompared with histopathological diagnosis.

Statistical analysis of the results were obtained by

using window based computer software device

with statistical Packages for Social Sciences

(SPSS-15).

Results:

Total 40 patients were included in this study.

Among the patients 28 (70.0%) were male and 12

(30.0%) were female. Male to female ratio was

2.33:1 .The mean± SD of age was 36.52±13.86 years

with a range of 12 to 70 years. Highest number of

patient (40.0%) were in the age group of 31-40 years

followed by 41-50 years (20.0%), 21–30 years

(15.0%), 11–20 years (12.5%), 51–60 years (7.5%)

and above 60 years (5.0%).

Most common presentation was back pain (87.5%)

followed by neurological deficit (75.0%). Other

clinical presentations included fever and kyphosisin 55.0% and 42.5% respectively. Spinalinvolvement of 2 (5.0%) were cervical, 25 (62.5%)were thoracic, 13 were (32.5%) lumbar. No onehad sacral involvement. Among the patients 5(12.5%) had single, 19(47.5%) had two, 12 (30.0%)had three and 4 (10.0%) had more than threevertebral body involvement. Ninety percent (36)of the patients presented with vertebral collapse.All patients had altered marrow signal intensityof involved vertebrae. Six patients (15.0%) hadposterior element involvement. Eighteen (45.0%)patients had kyphosis and 28 (70.0%) patients hadend plate disruption. Disc involvement and signalchange (high signal intensity of disc in T2WI) werepresent in 35 (87.5%) patients. Well defined andill-defined Para-spinal abnormal signal werepresent in 32 (82.0%) and 7 (18.0%) respectively.Margin of abscess wall was thin & smooth in 30(77.0%) patients and thick & irregular in 9 (23.0%)patients. MRI features of cord compression andcord compression with myelopathy was present in

19 (47.5%) and 10 (25.0%) patients respectively.

MRI diagnosis 28 (70.0%) was tuberculous

spondylitis, 7 (17.5%) were pyogenic spondylitis and

rest 5 (12.5%) were spinal metastasis.

Histopathological diagnosis of 28 (70.0%) patients

was tuberculous spondylitis, 8 (20.0%) were

pyogenic spondylitis and rest 4 (10.0%) were spinalmetastasis .Out of all cases 28 were diagnosed astuberculous spondylitis by MRI and among them

26 were confirmed by histopathology. They were

true positive. Two cases were diagnosed as having

tuberculous spondylitis by MRI but not confirmedby histopathology. That was false positive. Out of12 cases of non-tuberculous spondylitis which wereconfirmed by MRI, 2 were confirmed astuberculous spondylitis and 10 were non-tuberculous spondylitis by histopathology. Theywere false negative and true negative respectively.

Sensitivity, specificity, positive predictive value,negative predictive value and accuracy of MRI inthe diagnosis of tuberculous spondylitis were92.86%, 83.33%, 92.86%, 83.33% and 90.00%respectively.

Performance of Magnetic Resonance Imaging in the Diagnosis Nazma Farzana Chowdhury et al

69

Table I

Relationship of MRI and histopathological

diagnosis of patient

MRI Histopathology Total

Positive Negative

Positive 26 (92.9)* 02 (16.7) 28 (70.0)

Negative 02 (07.1) 10 (83.3) 12 (30.0)

Total 28 (100.0) 12 (100.0) 40 (100.0)

*Figure within parentheses indicates in columnpercentage.

Table II

Showing the validity test results

Value (%)

Sensitivity 92.86

Specificity 83.33

PPV (Positive predictive value) 92.86

NPV (Negative predictive value) 83.33

Accuracy 90.00

Fig 1 : Tuberculous spondylitis of L5 - S1,

(a,b,c)

Magnetic resonance image of the lumbo

sacral spine in a 35 years old female

presented with low back pain,

(a) Pre – Gadolinium T1 – weighted,

(b) T2 - weighted in sagittal plane show

altered marrow signal intensities of

L5 and S1 vertebral bodies with

prevertebral abscess,

(c) Post - Gadolinium T1 - weighted in

sagittal plane shows heterogenous

enhancement of involved vertebra as

well as thin and smooth enhancement

of prevertebral abscess.

Fig 2 : Tuberculous spondylitis of D7 (a, b,

c). MRI of the thoracic spine in a 40

years old female presented with back

pain,

(a) Pre – Gadolinium T1 - weighted.

(b) T2 - weighted in sagittal plane showaltered marrow signal intensities ofD7 vertebral body with cordcompression. Adjacent hyper-hypointense prevertebral abnormalsignal and epidural mass are present,

(c) Post - Gadolinium shows heterogenousenhancement of D7 vertebral bodiesas well as thin and smooth rimenhancement of prevertebral andepidural abscess.

Bangladesh Journal of Radiology and Imaging Vol. 22(2): July 2014

70

Discussion:

Spondylitis is the most common osseous

manifestation of Mycobacterium tuberculi

infection. Although treatable, it continues to cause

significant mortality and morbidity. Early diagnosis

through familiarity with its imaging characteristics

is essential to permit rapid treatment and prevent

potential life-limiting consequences10.

In the present study, out of 40 patients Male and

female were 28 (70.0%) and 12 (30.0%) respectively.

The ratio between male and female was 2.33:1.Bajwa11 evaluated the role of MRI in assessingthe extent of disease in spinal tuberculosis in adescriptive study and out of 60 cases in their study33 were males (55%), 27 were female (45%). Sinanet al12 in their study reported that the majority(n=18, 60%) of the 30 patients were males.

In the present study, the mean age ± SD was 36.52± 13.86 years with a range of 12 to 70 years. Sinan

et al12 in their study reported that the majority of

the 30 patients were males was in the 30-49 year

age group (43%). Bajwa11 evaluated the role of MRI

in assessing and mean age which was 33 years

with a range of 14-36 years.

Most common presentation was back pain (87.5%)followed by neurological deficit (75.0%). Otherclinical presentation included fever and spinaldeformity/kyphosis which were 55.0% and 42.5%respectively. Cormican et al¹³ in their study

reported that back pain, neurological, and

constitutional symptoms were present in 100%,

29%, and 38% respectively. Sinan et al12 in their

study reported that the most common clinical

presentation was backache (73.3%) followed by

fever (63.3%) and malaise (36.6%). Bajwa11 in their

study showed that the most common symptom was

backache in 38 cases (63%). Spinal cord

compression was found in 16 cases (26.6%).

MRI of patients showed that out of 40 patients,

site of spinal involvement of 2 (5.0%) was cervical,

25 (62.5%) was thoracic, 13 (32.5%) was lumbar.

No one had sacral involvement. Among the

patients 5 (12.5%) had single, 19(47.5%) had two,

12 (30.0%) had three and 4 (10.0%) had more than

three vertebral bodies involvement. Ninety

percent (36) presented with vertebral collapse. All

patients had altered marrow signal intensity of

involved vertebrae. Six patients (15.0%) had

posterior element involvement. Eighteen (45.0%)

patients had kyphosis and 28 (70.0%) patients had

end plate disruption. Disc involvement and signal

change (high signal intensity of disc, T2W1) were

present in 35 (87.5%) patients. Well-defined and

ill-defined paraspinal abnormal signal were

presents in 32 (82.0%) and 7 (18.0%) respectively.Margin of abscess wall were thin & smooth in 30(77.0%) patients and thick & irregular in 9 (23.0%)patients. MRI features of cord compression andcord compression with myelopathy were presentin 19 (47.5%) and 10 (25.0%) patients respectively.Bajwa11 in their study showed that the most

commonly affected level was thoracolumbar spine

(45%). Kotze and Erasmus14 in a study found that

typical findings of vertebral column involvement

Fig 3 : Tuberculous spondylitis of D8 – D9

(a, b, c) Magnetic resonance image of the

thoracic spine in 12 years old boy, presented

with back pain and spinal deformity.

(a) Precontrast T1- weighted.

(b) T2- weighted in sagittal plane shows

wedge shaped collapse of D9 vertebra

with altered marrow signal intensity.

Adjacent prevertebral well defined

abnormal signal and kyphotic deformity

is seen.

(c) Post contrast coronal T1 weighted

image show thin and smooth rim

enhancement of paraspinal abscess.

Performance of Magnetic Resonance Imaging in the Diagnosis Nazma Farzana Chowdhury et al

71

(a) (b) (c)

were seen in all patients, namely a) Multiple levels

involvement, b) Paravertebral abscesses and c)

Thoracic spine involvement more than the lumbar

spine. In their study nearly in all cases

intervertebral disc involvement was noted and

Posterior longitudinal ligaments were intact in all

but 1(One) patient, even though there was some

elevation in a number of patients. Abscess walls

were also found to be thick instead of thin as

expected. Bajwa11 in their study showed that spinal

cord compression was found in 16 cases (26.6%)

and most commonly affected level was

thoracolumbar spine (45%) and only 3 cases (5%)

were having more than one level involvement.

Other findings of tuberculosis spine were reduced

intervertebral disc space (95% cases), wedge

collapse of the body in 18 (30% cases), complete

destruction of the body in 12 (20% cases), para-

spinal abscess in 24 (40% cases), calcification in 18

(30% cases) and cord compression in 16 cases

(26.6% cases).

In the present study out of 40 patients, 28 (70.0%)

were diagnosed by MRI as tuberculous spondylitis,

7 (17.5%) were pyogenic spondylitis and rest 5

(12.5%) were spinal metastasis. Out of 40 patients,

histopathological diagnosis in 28 (70.0%) was

tuberculous spondylitis, 8 (20.0%) pyogenic

spondylitis and rest 4 (10.0%) were spinal

metastasis. Harada et al15 in a study concluded

that MR imaging is a very useful technique for

differentiation of tuberculous spondylitis from

pyogenic spondylitis.

Among the 28 cases of tuberculous spondylitis, 26

cases was true positive and 2 cases were false

positive. Among non-tuberculous spondylitis 2

cases were false negative and 10 were true

negatives. In the present study sensitivity,

specificity, positive predictive value, negativepredictive value and accuracy of MRI in thediagnosis of tuberculous spondylitis were 92.86%,83.33%, 92.86%, 83.33% and 90.00% respectively.

Jung et al.9 in their study reported that sensitivity,

specificity, and accuracy of MRI in the diagnosis of

tuberculous spondylitis were 100% (20/20), 80% (16/

20), and 90% (36/40). Danchaivijitr et al 6 reported

that the overall sensitivity and specificity of MRI

for spinal tuberculosis were 100% and 88.2%

respectively. They reported that the most useful

three MR imaging features with high sensitivity

and specificity (> 80%) were endplate disruption

(100%, 81.4%), paravertebral soft tissue (96.8%,

85.3%), and high signal intensity of intervertebral

disc on T2WI (80.6%, 82.4%). In their study they

also reported that high sensitivity but low specificity

signs in MRI included bone marrow edema (90.3%,

76.5%), bone marrow enhancement (100%, 42.5%),

posterior element involvement (93.5%, 76.5%),

canal stenosis (87.1%, 26.5%), and spinal cord or

nerve root compression (80.6%, 38.2%) and low

sensitivity but high specificity features in MRI were

intervertebral disc enhancement (63.3%, 84.2%),

vertebral collapse (58.1%, 85.3%), and kyphosis

deformity (67.7%, 82.4%).

Conclusion:

The current study showed that MRI can be used

as a reliable tool with which we can assess

tuberculous spondylitis and can plan the

subsequent appropriate management in majority

of cases.

References:

1. Gonzalez-Martín J, García-García JM,Anibarro L, Vidal R, Esteban J, Blanquer R,Moreno S, Ruiz-Manzano J. ConsensusDocument on the Diagnosis, Treatment andPrevention of Tuberculosis. Arch Bron-

coneumol. 2010; 46(5):255-274.

2. Sharif HS, Morgan JL, al Shahed MS, alThagafi MY. Role of CT and MR imaging inthe management of tuberculous spondylitis.Radiol Clin North Am.1995; 33(4):787-804.

3. Moorthy S and Prabhu NK. Spectrum of MRImaging Findings in Spinal Tuberculosis.AJR. 2002 ; 179: 979-983.

4. Osborn AGDiagnostic Neuroradiology. 1st ed.India, Mosby; 2009. 822

5. Hidalgo JA. Pott Disease, [online].2011 [Lastupdated 2012 Jul 13, cited 2012 Nov6].Available from: http://emedicine.medscape.com/article/226141

6. Danchaivijitr N, Temram S, ThepmongkholK, Chiewvit P. ‘Diagnostic accuracy of MRimaging in tuberculous spondylitis’, Med

Assoc Thai. 2007; 90(8):1581-1589.

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7. Akman S, Sirvanci M, Talu U, Gogus A,

Hamzaoglu A. Magnetic resonance imagingof tuberculous spondylitis. Orthopedics; 2003.26(1):69-73.

8. Sharif HS .Role of MA imaging in themanagement of spinal infections. AJR. ; 1992.158:1333-1345.

9. Jung NY, Jee WH, Ha KY, Park CK, ByunJY. Discrimination of Tuberculous Spondylitisfrom Pyogenic Spondylitis on MRI. AJR.2004;182(6):1405-1410.

10. Currie S, Galea-Soler S, Barron D,Chandramohan M, Groves C. MRIcharacteristics of tuberculous spondylitis. Clin

Radiol. 2011; 66(8):778-787.

11. Bajwa GR . Evaluation of the role of MRI inspinal Tuberculosis: A study of 60 cases. Pak

J Med Sci. 2009; 25(6): 944-947.

12. Sinan T, Al-Khawari H, Ismail M, Ben-Nakhi

A, Sheikh M. Spinal tuberculosis: CT and MRI

features. Ann Saudi Med 2004;24(6):437-441.

13. Cormican L, Hammal R, Messenger J,

Milburn H. Current difficulties in the

diagnosis and management of spinal

tuberculosis. Postgrad Med. 2006; 82(963):

46-51.

14. Kotze DJ and Erasmus LJ. MRI findings in

proven Mycobacterium tuberculosis (TB)

spondylitis, SA Journal of Radiology. 2006;

12(1): 6-12.

15. Harada Y, Tokuda O, Matsunaga N. Magnetic

resonance imaging characteristics of

tuberculous spondylitis vs. pyogenic

spondylitis. Clin Imaging. 2008; 32(4):303-309.

Performance of Magnetic Resonance Imaging in the Diagnosis Nazma Farzana Chowdhury et al

73

Abstract :

Background : Adenomyosis is a common

condition that predominantly affects women in the

late reproductive years. Because of nonspecific

nature of the clinical presentation, the diagnosis is

traditionally not made prior to surgery. Pelvic

sonography, particularly since the introduction of

the transvaginal approach, has provided a new tool

for the detection of adenomyosis.

Objectives: The purposes of this cross sectional

study was to determine the sensitivity, specificity,

accuracy, positive predictive value and negative

predictive value of Transvaginal sonography (TVS)

in the diagnosis of adenomyosis.

Materials and methods: This study was carried

out in the department of Radiology and Imaging

of Enam Medical College and Hospital during

January 2014 to May 2015. Transvaginal

sonography was done in 135 women suspected of

having adenomyosis. Among them hysterectomy

and histopathology were done only in 102 cases.

TVS findings and histopathological reports analysis

was done using SPSS-13.

Results: According to our study the sensitivity of

TVS was 92.4%, specificity 88.8%, positive

predictive value (PPV) 93.8%, negative predictive

value 86.4% and accuracy 91% in the diagnosis of

adenomyosis. Conclusion: With the validity test

results, it can therefore be concluded that TVS

provide an accurate diagnosis of adenomyosis.

Key Words: Adenomyosis, Transvaginal

sonography (TVS)

Evaluation of Accuracy of Transvaginal

Sonography in Diagnosis of Adenomyosis with

Histopathological CorrelationTARANA YASMIN1, MASHAH BINTE AMIN 2, SHEULY BEGUM3, ASISH KUMAR SARKAR4,

AUROBINDO ROY5, MD ANISUR RAHMAN KHAN6, MD KHALILUR RAHMAN7

1 & 2 Assistant Professor, Department of Radiology & Imaging, Enam Medical College & Hospital (EMCH). 3.Associate Professor, Department of Gynecology & Obstetrics, EMCH. 4. Medical Officer, Department of Radiology& Imaging, BSMMU, 5. Radiologist, Dhaka Medical College Hospital (DMCH), 6. Assistant Professor, Departmentof Radiology & Imaging, Dhaka Medical College Hospital, 7. Associate Professor, Department of Radiology &Imaging, Dhaka Medical College Hospital

Introduction:

Adenomyosis is defined by the presence of ectopic

endometrial glands and stroma within the

myometrium. The presence of ectopic endometrial

glands and stroma induces a hypertrophic and

hyperplastic reaction in the surrounding

myometrial tissue. Adenomyosis is a fairly common

gynecological condition. The reported frequency

of this condition varies widely, ranging from 5% to

70% 1,2 . Adenomyosis is most commonly present

in women within the older reproductive age group.

Most patients with adenomyosis are asymptomatic.

Symptoms related to adenomyosis include

dysmenorrhea, dyspareunia, chronic pelvic pain,

and menstrual meno-metrorrhagia. Physical

examination may reveal an enlarged, tender

uterus. Adenomyosis can also be associated with

other conditions, such as leiomyoma, endometrial

polyps, and endometriosis3. The establishment of

the clinical diagnosis of adenomyosis is difficult

because of its vague presenting symptoms and

diagnosis without histo-pathological confirmation

is difficult to obtain. The preoperative diagnosis of

adenomyosis remains elusive, although the use ofsonography and MR imaging improves thediagnosis. The evaluation of endovaginalsonography in the diagnosis of adenomyosis hasreceived attention, with small series reporting

sensitivities and specificities of up to 87% and 98%

respectively 4,5,6,7. Because sonography is

frequently the initial imaging study in these

patients, improving the diagnosis of this disease

with sonography is important. If the correct

diagnosis is established uterus conserving therapy

is possible whereas hysterectomy is the definitive

BANGLADESH JOURNAL OF RADIOLOGY AND IMAGING 2014; VOL. 22(2): 74-80

treatment for debilitating adenomyosis. With

advent of high resolution sonography adenomyosis

can be diagnosed with a high degree of accuracy.

The purpose of this study was to evaluate the

accuracy of transvaginal sonography in the

diagnosis of adenomyosis and to characterize the

most commonly seen sonographic features.

Materials and Methods:

This cross sectional study was carried out in the

department of Radiology and Imaging of Enam

Medical College and Hospital from January 2014

to May 2015. Patients were referred for pelvic

sonography by gynecologists for a variety of

standard indications. Adenomyosis was suspected

and TVS was done in 135 cases. Out of these, 102

cases were included in the study as this patient

group had undergone hysterectomy and had histo-

pathological evaluation reports for review.

Patients were evaluated via transabdominal

ultrasonography followed by transvaginal

sonography as clinically indicated. The scans were

performed using a 3.5 MHz variable focus trans-

abdominal probe and subsequently by a 5-8 MHz

variable focus trans-vaginal probe. Color Doppler

interrogation was used during the study period.

The diagnosis of adenomyosis was made

prospectively at the time of the original scan.

We analyzed these women by recording age,

menstrual symptoms and associated symptoms for

clinical evaluation. Clinical indications of

hysterectomy were also recorded. Transvaginal

sonographic findings were recorded.

Histopathological reports of the hysterectomy

specimens were compared with trans-vaginal

sonographic findings.

Result:

A total 102 cases are included in this study. Age of

the patients ranged from 31 to 55 years. The largest

group was of peri-menopausal age (41-45 years)

contributing 44 % of total case in the study. Mean

(± SD) age of the patients was 42.7 ± 4.1 years.

(Table I)

Table I

Distribution of respondents according to age

(n= 102)

Age No of respondents Percentage (%)

31 -35 12 12

36-40 23 22

41-45 45 44

46-50 18 18

51-55 4 4

Main complaints included dysmenorrhea in 54 (52.9

%) cases followed by menorrhagia in 31 (30.4 %)

cases, irregular P/V bleeding in 15 (14.7%), lower

abdominal pain 12 (11.7%) and dyspareunia in 05

(4.9%) cases.

On per-vaginal examination tender bulky uterus

was found in 44 (43.14 %) cases followed by bulky

uterus 34 (33.33 %) cases, unhealthy cervix 02

(1.96%). Uterus was found normal in 22 (21.56%)

cases.

TVS findings showed that 65 (63.73 %) cases were

adenomyosis, 25(24.50 %) cases were fibroid, 05(4.9

%) were endometrial polyp, 04(3.92 %) were

endometrial hyperplasia and 3 (2.94 %) case were

cervicitis. (Table II)

Table II

Distribution of respondents according to TVS

findings. (n= 102)

Ultrasonographic No of Percentage

diagnosis (TVS) respondents (%)

Adenomyosis 65 63.73

Fibroid 25 24.50

Endometrial polyp 5 4.90

Endometrial hyperplasia 4 3.92

Cervicitis 3 2.94

Sonographically adenomyosis were diagnosed in

65 cases having following criteria – Commonest

uterine shape was globular, found in 35(53.84 %)

cases. Asymmetrical myometrial thickening was

seen in 45(69.23 %) cases. Heterogeneous

myometrial echotexture were present in 55 (84.62

Evaluation of Accuracy of Transvaginal Sonography in Diagnosis of Adenomyosis Tarana Yasmin et al

75

%) cases, Myometrial cyst was present in 50 (76.92

%) cases, increased myometrial vascularity was

observed in 43(66.15 %) cases, Endometrial

striation was present in 40 (61.54 %) cases.

Myometrial endometrial interface was absent in

30 (46.15 %) cases and 37 (56.92 %) cases had

indistinct endometrium. Other findings are shown

in Table III & (Figure 1 – 8)

Table III

Distribution of respondents according to TVS

features of adenomyosis (n= 65)

TVS features of No of Percentage

adenomyosis respondents (%)

Uterine size

Globular shape 35 53.84

Bulky uterus 24 36.92

Normal size 6 9.23

Myometrial thickness

Asymmetrical 45 69.23

Normal 20 30.77

Myometrial echotexture

Heterogeneous 55 84.62

Homogeneous 10 15.38

Myometrial cyst

Present 50 76.92

Absent 15 23.07

Myometrial vascularity

Increased 43 66.15

Normal 22 33.85

Endometrial striation

Present 40 61.54

Absent 25 38.46

Myometrial endometrial interface

Present 30 46.15

Absent 35 53.85

Endometrial stripe

Indistinct 37 56.92

Normal 28 43.08

Fig.-1 : Globular shaped uterus

Fig.-3: Heterogeneous myometrium

Fig.-2: Bulky uterus

Bangladesh Journal of Radiology and Imaging Vol. 22(2): July 2014

76

Associated sonographic findings with adenomyosis

were fibroid in 14 (21.53 %), endometrial polyp in

07 (10.77 %), endometrial hyperplasia in 05 (7.69%),

endometrioma in 04 (6.15 %) and cervicitis in 03

(4.62 %) cases.

Sonographically 65 lesions were benign. Among

the benign lesions 61 (93.85 %) cases were also

proved benign histopathologically and 04 (6.15 %)

other than adenomyosis. Among the 37 cases who

were sonographically diagnosed having diseases

other than adenomyosis, 05 (13.51 %) were

diagnosed as adenomyosis and 32 (86.49 %) were

other than adenomyosis. (Table-IV)

Fig.-4: Asymmetric myometrial thickness

Fig.-5: Myometrial cyst

Fig.-6: Endometrial Striation

Fig.-7: Indistinct endometrium

Fig.-8: Adenomyosis with fibroid

Evaluation of Accuracy of Transvaginal Sonography in Diagnosis of Adenomyosis Tarana Yasmin et al

77

In diagnosis of adenomyosis TVS showed that

the sensitivity was 92.4%, specificity 88.8%, positive

predictive value (PPV) 93.8%, negative predictive

value 86.4% and accuracy was 91.0%. (Table V).

Table V

Validity test for adenomyosis.

Validity test parameters value

Sensitivity 92.4%

Specificity 88.8%

Positive Predictive Value(PPV) 93.8%

Negative PredictiveValue(NPV) 86.4%

Accuracy 91%

Discussion :

Adenomyosis is characterized by an irregular endo-

myometrial junction, with endometrial glands and

stroma extending into the myometrium. When

adenomyosis involves the myometrium in a diffuse

manner, symmetric uterine enlargement is seen.

This occurs primarily as a result of smooth muscle

hypertrophy, in which the smooth muscle

interdigitates around endometrial glands and

stroma. If the adenomyosis is focal, uterine

enlargement may be asymmetric. The reason why

smooth muscle undergoes hypertrophy and

encircles areas of adenomyosis is unknown2.

Classically the clinical triad of uterine enlargement,

dysmenorrhea, and menorrhagia suggests

adenomyosis. However, the symptoms are so

nonspecific that the diagnosis is made

preoperatively in fewer than half of patients

undergoing hysterectomy8. But now-a-days the

advent of endovaginal US has substantially

improved the ability to diagnose adenomyosis.

Different US features of adenomyosis have been

reported in the literature, including uterine

enlargement, globular uterus, asymmetric

thickening of the anterior or posterior myometrial

wall, heterogeneous poorly circumscribed areas

within the myometrium, anechoic lacunae or cysts

of varying sizes, increased echotexture of the

Myometrium and linear endometrial striations 9,10.

In this study most patients were in 41-45 age group

(44%) with mean age of 42.7 ± 4.1 years. Most

frequent presenting complaints were

dysmenorrhea (53%) followed by menorrhagia

(30%). Most common pervaginal examination

findings were tender bulky uterus (43.14 %).

In our study common diagnostic sonological

findings were Globular shaped uterus in 35 (54%)

cases followed by bulky uterus in 24(37%) cases,

asymmetrical myometrial thickening in 45(69%)

cases. Heterogeneous myometrial echotexture

were seen in 55 (85%) cases. Myometrial cyst was

present in 50(77%) cases. 43 (66%) cases showed

increased myometrial vascularity. Endometrial

striation was present in 40 (62%) cases. Myometrial

endometrial interface was lost in 30 (46%) cases

and 37 (57%) cases had indistinct endometrium.

Different studies showed presence of cystic spaces

in the myometrium and posterior wall thickening

on pelvic sonography as features of

adenomyosis11,12,13,14. Ttransvaginal sonography

similarly describes cystic spaces and also shows

the finding of heterogeneous zones in the

myometrium as indicative of adenomyosis 4,5,6,7,

15. Sensitivities and specificities of endovaginal

sonography for the diagnosis of adenomyosis were

in the range of 80–87%4 and 74–96%7, respectively,

where presence of cystic spaces in the myometrium

was used as the diagnostic criteria. One author

Table IV

Showing distribution of adenomyosis by TVS and Histopathology (n=102)

Ultrasonographic findings Histopathological findings Total

Adenomyosis Others

Adenomyosis ( 65) 61 (93.85 %) 04 (6.15%) 65

Others(37) 05 (13.51 %) 32 (86.49%) 37

Total 66 36 102

Bangladesh Journal of Radiology and Imaging Vol. 22(2): July 2014

78

differed too, saying that the most common

sonographic finding in patients with adenomyosis

to be a uterus with a diffuse heterogeneous

echotexture (85%)6.

Our experience is similar to that reported by Fedele

and associates5. These investigators reported 80%

sensitivity and 74% specificity for transvaginal

sonography to detect diffuse adenomyosis5.

Reinhold and coworkers also reported a sensitivity

of 86%, specificity of 86%, PPV of 71%, and NPV of

94% in a group of 29 patients with pathologically

proven adenomyosis6. Botsis and colleagues

reported a sensitivity of 80% with a specificity of

90% in a group of 48 patients with diffuse

adenomyosis16. Brosens and coauthors reported a

sensitivity of 86% and specificity of 50% for the

use of transvaginal sonography in the identification

of adenomyosis17. Walsh and colleagues initially

noted the presence of small cystic spaces as an

important finding in patients with adenomyosis11.

Botsis and coworkers, who noted the existence of

lacunae in 83% of patients with adenomyosis16.

Reinhold and colleagues found 53% of patients with

a histologic diagnosis of adenomyosis had

myometrial cysts6. Our study also demonstrated

that the endometrial stripe was indistinct and

“shaggy” in appearance with adenomyosis in

37(57%) cases. The presence of a poorly defined

endometrial stripe may be more frequent in

patients with adenomyosis.1,18

In this study we found associated sonographiic

findings with adenomyosis were fibroid 14 (22%),

endometrial polyp 07 (11%), endometrial

hyperplasia 05 (8%), endometrioma 04 (6%),

cervicitis 03 (4%). Gynecology literature shows

that 60–80% of patients diagnosed with

adenomyosis show other pelvic pathology,

including fibroids, endometriosis, endometrial

polyps, and endometrial hyperplasia 19.

On tranvaginal sonogram, adenomyosis was

diagnosed in 65 (64%) cases and other than

adenomyosis in 37(36%) cases. Sonographically

65 lesions were adenomyosis, out of these

61(93.9%) were also proved histopathologically and

04 (6.1%) other than adenomyosis. Out of 37

sonographically diagnosed other lesions, 32

(86.5%) were also proved histopathologically but

05 (13.5%) cases were adenomyosis .According to

our study result sensitivity was 92.4%, specificity

88.8%, positive predictive value (PPV) 93.8%,

negative predictive value 86.4% and accuracy was

91% in diagnosis of adenomyosis by transvaginal

songrphy .

According to our study transvaginal sonography

has significant sensitivity, specificity, accuracy,

positive predictive value and negative predictive

value in the diagnosis of adenomyosis. Our study

was also comparable to other similar studies. So

we can conclude that transvaginal sonography is a

sensitive imaging tool in diagnosis of adenomyosis.

Conclusion :

Adenomyosis is a common finding in women of

reproductive age. Most women with adenomyosis

are asymptomatic. The diagnosis of adenomyosis

by sonography has been well defined and has

diagnostic capabilities comparable to MRI.

According to our study transvaginal sonography is

significantly sensitive, specific and accurate in the

diagnosis of adenomyosis. When a diagnostic

imaging modality is required for suspected

adenomyosis, Transvaginal sonography can be used

as an initial investigation due to its efficacy, safety,

and lower cost.

References:

1. Azziz R: Adenomyosis: Current perspectives.

Obstet Gynecol Clin North Am 16:221, 1989

2. Kurman RJ: Benign diseases of the

endometrium. In Blaustein A (Ed): Pathology

of the Female Genital Tract. 2nd Edition. New

York, Springer-Verlag, 1984, p 297

3 Bromley B, Shipp TD, Benacerraf B.

Adenomyosis: sonographic findings and

diagnostic accuracy. J Ultrasound Med 2000;

19:529–534.

4. Fedele L, Bianchi S, Dorta M, et al.

Transvaginal ultrasonography in the

differential diagnosis of adenomyoma versus

leiomyoma. Am J Obstet Gynecol 1992;

167:603–606

5. Fedele L, Bianchi S, Dorta M, Arcaini L,

Zanotti F, Carinelli S. Transvaginal

Evaluation of Accuracy of Transvaginal Sonography in Diagnosis of Adenomyosis Tarana Yasmin et al

79

ultrasonography in the diagnosis of diffuse

adenomyosis. Fertil Steril 1992; 58:94–97

6. Reinhold C, Atri M, Mehio A, et al. Diffuse

uterine adenomyosis: morphologic criteria

and diagnostic accuracy of endovaginal

sonography. Radiology 1995; 197: 609–614

7. Atzori E, Tronci C, Sionis L. Transvaginal

ultrasound in the diagnosis of diffuse

adenomyosis. Gynecol Obstet Invest 1996;

42:39–4

8. Lee NC, Dicker RC, Rubin GL, et al:

Confirmation of the preoperative diagnoses

for hysterectomy. Am J Obstet Gynecol 1984;

150:283,

9. Hirai M, Shibata K, Sagai H. Transvaginal

pulsed and color Doppler sonography for the

evaluation of adenomyosis. J Ultrasound Med

1995; 14:529-532

10. Kepkep K, Tuncay YA, Göynümer G, Tutal

E. Transvaginal sonography in the diagnosis

of adenomyosis: which findings are most

accurate? Ultrasound Obstet Gynecol 2007;

30:341–345.

11. Walsh JW, Taylor KJ, Rosenfield AT. Gray

scale ultrasonography in the diagnosis of

endometriosis and adenomyosis. AJR 1979;

132: 87–90

12. Bohlman ME, Ensor RE, Sanders RC.

Sonographic findings of adenomyosis in the

uterus. AJR 1987; 148:765–766

13. Siedler D, Laing FC, Brooke J, et al. Uterineadenomyosis: a difficult sonographicdiagnosis. J Ultrasound Med 1987; 6: 345–349

14. Murao F, Hata K, Shin K, et al.Ultrasonography for the diagnosis ofadenomyosis. Acta Obstet Gynaec Jpn 1986;38:2073–2077

15. Ascher SM, Arnold LL, Patt RH, et al.Adenomyosis: prospective comparison of MRimaging and transvaginal sonography.Radiology 1994; 190: 803–806

16. Botsis D, Kassanos D, Antoniou G, et al:Adenomyoma and leiomyoma: Differentialdiagnosis with transvaginal sonography. J

Clin Ultrasound 26:21, 1998

17. Brosens JJ, De Souza MN, Barker FG, et al:Endovaginal ultrasonography in the diagnosisof adenomyosis uteri: Identifying thepredictive characteristics. Br J Obstet

Gynaecol 102:474, 1995

18. Marcus CC: Relationship of adenomyosis uterito endometrial hyperplasia and endometrialcarcinoma. Am J Obstet Gynecol 82:408, 1961

19. Vercellini P, Ragni G, Trespidi L, et al.Adenomyosis: a déjà vu? Obstet Gynecol Surv

1993; 48:789–794

Bangladesh Journal of Radiology and Imaging Vol. 22(2): July 2014

80

Abstract:

Objective of this study was to determine whether

color Doppler interrogation of a thyroid nodule can

aid the prediction of malignancy. We obtained color

Doppler images of thyroid nodules undergoing

sonography along with guided FNAC.62 patients

of solitary thyroid nodules were evaluated.

Sonographic findings relevant to benign and

malignant nodules were recorded and correlated

with cytological & histo-pathological findings. The

color Doppler appearances of each nodule were

graded from 0 (zero) for no visible flow up to 4(Four)

for extensive intra nodular flow. Out of 62,40 cases

were diagnosed as benign and 22 cases were

malignant.52 nodules were solid and among solid

nodules 18 were found as malignant.The prevalence

of malignancy was more in solid nodules which

were hyper-vascular having extensive intra-nodular

vascularity.The color characteristics of thyroid

nodules,however, cannot be so much useful to

predict or exclude malignancy confidently because

14% of solid non hyper-vascular nodules were found

as malignant.So it becomes predictive for

malignancy only when multiple signs are

simultaneously present in a thyroid nodule and

FNAC or biopsy is needed for confirmation.

Keywords: Solitary thyroid nodule, High

resolution sonography, Color Doppler.

Introduction:

Thyroid nodule is a discrete lesion and a common

clinical condition. Solitary thyroid nodules are

commonly present in up to 50% of the elderly

Role of Color Doppler and High Resolution

Sonography in the Prediction of Malignant

Thyroid Nodules with Cyto and Histo-

pathological correlationMAKSUDA BEGUM1, MOLLA ERSHADUL HAQUE2, MAHBUB ALAM3, SHAHIDUL ISLAM4,

RASHEDA PERVIN5, BIDOURA TANIM6, MD ANISUR RAHMAN7

1. Assistant professor of Radiology & Imaging, National Institute of Traumatology and Orthopedic Rehabilitation(NITOR), 2. Assistant Professor, Department of orthopedics, Shaheed Suhrawardy Medical College, 3. IndoorMedical Officer, NICRH, 4. Associate Professor & Head, Department of Radiology & Imaging, NITOR, 5. Radiologist,NITOR, 6. Assistant Professor, Department of Radiology & Imaging, National Institute of Ophthalmology (NIO)Hospital, Dhaka, 7. Assistant Professor, Department of Radiology & Imaging, Rajshahi Medical College Hospital

population. Up to 20% thyroid nodules are found

clinically by palpation and up to 70% in sonographic

studies1.

Solitary thyroid nodule is common in females than

males with a ratio of 5:1 and prevalence mainly

depends on age, sex, iodine intake, diet and

environmental exposure. Though solitary thyroid

nodule is common in women, malignancy is

common in men2.

The high resolution sonography is effective in

discovery of large number of new thyroid nodules

which are obscured clinically. Gray scale and color

Doppler sonography are used to differentiate

benign from malignant nodules. Several gray scale

sonographical characteristics have found to be

highly suggestive of malignancy including micro-calcifications and irregular margins. Thyroid glandis one of the most vascular organs in the body.Color Doppler flow imaging is permitted to assessthe blood supply in addition to morphology. SoDoppler may be useful in detecting type of

pathology. High frequency transducers (7-12 MHz)

are used for thyroid imaging.

Rich vascularization of thyroid gland can be easily

seen, which is most pronounced at the upper and

lower pole. Mean diameter of the artery is 1-2 mm.

The veins may be up to 8 mm in diameter. Peak

systolic velocities are 20-40 cm/sec in major thyroid

arteries and 15-30 cm/sec in intra parenchymal

arteries3.

Doppler examination can also be used to monitor

the response to therapy in the patients of grave’s

BANGLADESH JOURNAL OF RADIOLOGY AND IMAGING 2014; VOL. 22(2): 81-87

disease. Following treatment significant decrease

in vascularity and the velocities of thyroid vessels

are seen. Several reports have described no

correlation between presence of flow on color

Doppler sonography and malignancy, particularly

when color flow is considered as an isolated

criterion 4. Others have suggested that a pattern

of either spotty intra-nodular flow or hyper vascular

central flow on color Doppler may be associated

with malignancy 5. Prediction of malignancy using

sonography still remains difficult. Since there is

overlap of sonographic features between benign

and malignant thyroid nodules, it is not possible

to distinguish a benign follicular adenoma from

follicular carcinoma by sonography. FNAC, core

biopsy, frozen section, vascular and capsular

invasion can only be evaluated on histological

specimen, so sonographic features are usually

corroborated with histopathology for

differentiating various thyroid nodules 6.

Color Doppler findings that may be useful in

differentiation, is the distribution of the vessels.

Quantitative analysis of flow velocities is not

accurate in differentiating benign from malignant

nodules. With presently available high resolution

color Doppler systems some degree of vascularity

is demonstrated in all nodules. Two types ofvascular distribution are seen: a) Nodules withperipheral vascularity and b) Nodules with internalvessels, which may or may not be associated withperipheral vessels 7.

Objectives: The purpose of this study was to

determine whether color Doppler sonography can

be used to diagnose or exclude malignancy in a

thyroid nodule.

Materials and Methods:

This cross sectional prospective study was

conducted in the department of Radiology &

Imaging, NICRH, Dhaka in collaboration with

department of Otolaryngology, Surgery & Medical

Oncology. We performed color Doppler Sonography

of all thyroid nodules which were referred for high

resolution sonography with clinically suspected

thyroid nodule.

The study was carried out during the period of

January 2011 to December 2012. Total 62 cases

clinically with solitary thyroid nodules were

selected for this study. Detail history about the

illness, chief complaints, family history, history of

radiation exposure in the neck region, weight gain

or loss and heat intolerance was recorded.

Inclusion Criteria:

All clinically diagnosed patients with solitary

thyroid nodule at or above the age of 18 years were

included in the study.

Exclusion criteria:

Pateint with diffuse thyroid disease or with

previous H /0 any malignancy were excluded from

the study. Nodules of <1 cm size were also excluded

because the recommended measurement for USG

guided FNAC is 1.5 cm8.

Method of performing examination:

Sonography of neck was performed by using

SIEMENS ACCUSON x 300 and SIEMENS G50

with 5-10 MHZ transducers. After localizing the

nodule following features were noted: Internal

consistency (solid/purely cystic/ mixed solid &

cystic), echogenicity in relation to the adjacent

thyroid parenchyma, margin, presence of

calcification, peripheral sonolucent halo and

presence and distribution of blood flow signals.

Thyroid nodules were diagnosed as benign or

malignant on the basis of sonographic features.

Later the findings were correlated with USG guided

FNAC findings. Biopsy reports were compared in

few patients who underwent surgery. Enlarged

lymph nodes were detected and noted.

The collected data was analyzed using window

based computer software device with packages for

social sciences (SPSS-15). For the validity of study

outcome, sensitivity, specificity, accuracy, positive

predictive value and negative predictive values of

USG was calculated out after confirmation by

FNAC and histopathology.

Parameters were optimized in all cases to show

slow flow. All color images were obtained before

FNAC. Color flow in each nodule was characterized

without knowledge of cytologic or pathologic

findings by the consensus of at least 2 of 3 staff

Bangladesh Journal of Radiology and Imaging Vol. 22(2): July 2014

82

radiologist as follows : 0 for no visible flow, 1 for

minimal internal flow without a peripheral ring, 2

for a peripheral ring of flow (defined as > 25% of

the nodule’s circumference) but minimal or no

internal flow, 3 for a peripheral ring of flow and a

small to moderate amount of internal flow, and 4

for extensive internal flow with or without a

peripheral ring 9.

Results:

Out of total 62 patients 40 (65%) were benign and

22 (35%) were malignant. Out of 62 patients 52

(85%) were female and 10 (15%) were male. Age

range was 18-66 yrs. Mean (+ SD) age of the

patients were 39.5 ((+ 11.5) yrs. Out of 62 cases 39

(63.3%) were in right lobe and 19 (30%) were in

left lobe and 2 (3.3%) were in isthmus.

Table I

Sonographic characteristics.

Features No of Benign cases (40) No of Malignant Cases (22)

Total Percentage Total Percentage

Echotexture

Hyperechoic 13 32.5 02 9.1

Isoechoic 19 47.5 03 13.6

Hypoechoic 03 7.5 17 77.3

Anechoic 05 12.5 00 00

AP/ Trans Ratio

Wider then taller 36 90 06 27.3

Taller than wider 04 05 16 72.7

Internal Contents

Solid 34 85 18 81.8

Purely cystic 01 2.5 01 4.5

Cyst with thinsepta 02 5 01 4.5

Mixed 01 2.5 02 9.1

Spongiform 02 5 00 00

Margin

Well defined 36 90 04 18.2

Ill defined 04 10 18 81.8

Halo

Complete halo 35 87.5 07 31.8

Incomplete halo 05 12.5 15 68.2

Calcification (n = 24)

Coarse 06 66.6 01 6.7

Micro 01 11.1 14 93.4

Egg shell 02 22.2 00 00

Vascularity

Intarnodular (n=21) 06 15 15 68.2

Perinodular (n=39) 30 75 09 40.9

No flow (n=02) 02 5 00 00

Role of Color Doppler and High Resolution Sonography in the Prediction of Malignant Maksuda Begum et al

83

Table II

Color flow characteristics of the nodules

Color type No of Benign cases (40) No of Malignant Cases (22)

Total Percentage Total Percentage

0 02 5 00 00

1 20 50 01 4.5

2 07 17.5 03 13.7

3 12 30 03 13.7

4 03 7.5 11 50

Pictures of color Doppler sonographic features:

Pictures of gray scale sonographic features:

Case 1: Follicular adenoma

having complete peripheral halo

Case 2: Mixed nodule of

Follicular carcinoma.

Case 3: Follicular carcinoma

having incomplete peripheral halo

Case 4: Extensive intra-

nodular flow of Follicular

carcinoma.

Case 5: Partial peri-nodular

flow of Follicular adenoma.

Case 6: Extensive peri-nodular flow

of Follicular adenoma.

Bangladesh Journal of Radiology and Imaging Vol. 22(2): July 2014

84

Table III

Cyto and histopathological diagnosis.

Benign Lesions Total 40 Percentage

Follicular adenoma 22 55

Nodular hyperplasia 11 27.5

Colloid nodule 07 17.5

Malignant Lesions Total 22 Percentage

Papillary carcinoma 15 68.18

Follicular carcinoma 07 31.8

Medullary carcinoma 00 ——-

Discussion

Sonography is a choice of investigation in

evaluating thyroid nodules. Many sonographic

features have been described to differentiate benign

and malignant nature of the nodule. The present

study was done on 62 patients.

The present study showed 85% of benign nodules

are solid, whereas 81.8% of malignant nodules are

solid. The study done by Hegde et al showed that

most benign and malignant nodules are solid,

making it difficult to use this criterion for

differentiating the two.10

In the present study, 90% of nodules had well-

defined margins and 10% of nodules with ill-defined

margins were benign and 81.8% of the nodules

having ill-defined margins and 18.2% with well-

defined margins were malignant nodules. The

study done by Papini E et al showed that nodule

having well defined margin were benign and nodule

having ill-defined margin were mostly malignant

nodules11.

In the present study 87.5% of the nodules which

had peripheral complete halo were benign nodules

and 68.2% of the nodules which had peripheral

incomplete halo were malignant nodules. The study

done by Wienke et al showed that in 93.7% benign

nodules there were peripheral complete halo and

in 83.3 % malignant nodules there was peripheral

incomplete halo12. In the present study coarse

calcification were seen in 66.6 % and peripheral

egg shell calcification in 22.2 % of benign nodules

and micro-calcification was seen in 93.4 % of

malignant nodules. The study done by Wienke et

al also showed that coarse calcification was seen

in 72% and peripheral egg shell calcification were

seen in 35% of benign nodules, whereas micro-

calcifications were seen in 16% of malignant

nodules12.

In the present study perinodular vascularity was

seen in 75 % of benign nodules and 40.9 % of

malignant nodules, whereas Intra nodular

vascularity was seen in 68.2 % of malignant nodules.

The study done by Propper et al showed that

perinodular vascularity is seen in benign nodules

and intra nodular vascularity is seen in malignant

nodules.13

In the present study of 62 cases of solitary thyroid

nodules, Sonographic diagnosis was made as benign

in 42 cases and 40 cases were confirmed as benign

by histopathology. Remaining 2 cases were

diagnosed as malignant by histopathology.

Sonologically these 2 cases showed features of

benign nodule such as AP/TRANS ratio < 1,

isoechoic nodule, well defined, peripheral thick

complete halo.

In the present study of 62 cases, Sonographic

diagnosis was made as malignant in 25 cases, 22

cases were confirmed as malignant by

histopathology. Remaining 3 cases were diagnosed

as benign by histopathology. Sonologically these 3

cases showed features of malignant nodule such

as AP/TRANS > 1, mixed nodule, peripheral

incomplete halo and intra-nodular vascularity.

Gray scale sonography in our study showed a

sensitivity of 83.5%, Specificity of 87.2%, Accuracy

of 76.9 %, Positive predictive value of 72.5% and a

Negative predictive value of 91.7%.

The sonographic mismatch of predicting benign

and malignant nodules in the present study was

mainly noted in cases of follicular adenoma and

follicular carcinoma. They both differ only in the

vascular and capsular invasion which is very

difficult to diagnose on sonography. Hence in such

cases histo-pathological examination only gives the

correct diagnosis.

In present study, sonography was able to

differentiate benign from malignant nodules with

sensitivity of 83.5% and specificity of 87.2 % which

Role of Color Doppler and High Resolution Sonography in the Prediction of Malignant Maksuda Begum et al

85

correlates with above study. The study done by

Som et al showed that sonography has a sensitivity

of 75 % and specificity of 83 % in differentiating

benign from malignant nodules.14

This study examined the role of color Doppler

sonography in thyroid nodules and our results

showed that both the solid nature and extensive

internal blood flow are strong points in favor of

malignancy. Indeed, the combination of hyper

vascularity and a solid nature had a high likelihood

of malignancy (41.9%) in our series. In a larger

study of more than 100 patients with cold nodules,

a hypervascular pattern alone was not a statistically

significant finding for the prediction of

malignancy15. Another large study that included

30 cases of papillary carcinoma found no significant

difference in the color flow patterns of benign

versus malignant nodules16. Another large study

of 300 cold nodules, which compared color Doppler

with Power Doppler sonography including 20 cases

of papillary carcinoma had results similar to ours,

with a hypervascular color Doppler pattern

common but not diagnostic of papillary cancer.

About 30% of the hypervascular solid nodules

(those with color type 3) in our series were benign.

In addition, about 14% of the non hypervascular

solid nodules were malignant.

Conclusion:

From the present study it was noted that

sonographic features such as wider than taller in

shape, isoechogenicity / hyperechogenicity, purely

cystic nodule / cystic with thin septa / spongiform

appearance, well defined margins, peripheral

complete halo, egg shell / coarse calcification and

perinodular vascularity are highly predictive of

benign nodules.

Sonographic features such as taller than wider

shape, marked hyperechogenicity or

hypoechogenecity, ill-defined margins, peripheral

incomplete halo, micro-calcification and intra-

nodular vascularity with or without peri-nodular

vascularity are highly predictive of a malignant

nodule.

Sonography is specific (83:5%) and sensitive (87.2

%) in differentiating benign from malignant nodule.

But the role of color Doppler sonography in the

evaluation of a thyroid nodule for malignancy has

not been defined successfully. In conclusion, solid

hypervascular thyroid nodules have a higher risk

of malignancy than cystic or non hypervascular

lesions. However, the color Doppler characteristics

of a thyroid nodule cannot be used to predict or

exclude malignancy confidently, rather it becomes

predictive for malignancy only when multiple signs

are simultaneously present in a thyroid nodule,

and FNAC or biopsy is needed for confirmation.

References:

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aspiration biopsy of thyroid nodules:

Experience in a cohort of 944 pts. AJR 2009;

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Anisul Moula. “Ultrasonographic Evaluation

of Echogenic Thyroid Nodule with

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4. Shimamoto K, Endo T, Ishigaki T, Sakuma

S, Makino N. Thyroid nodules: evaluation

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7. Cerbone G ,Spieza S, Colao A, et al.Power

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nodules : follow-up results. Horm Res 1999;

52:19-24. CrossRef Medline.

8. Burch HB, Jose RM, Smile SR, Iyengar

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operative diagnosis of thyroid swelling. Indian

J Pathol Microbiol 2002; 45(4):393-396.

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10. Hedge A, Gopinathan A, Abu Bakar A, OoiCC, Koh YY, Lo RH. A method in the madnessin ultrasound evaluation of thyroid nodules.Med J 2012; 53(11): 766-773.

11. Papini E, Guglielmi R, Bianchini A. Risk ofmalignancy in non-palpable thyroid nodules:predictive value of ultrasound and color-Doppler features. J Clin Endocrinol Metab.

2002; 87:1941-6.

12. Wienke JR, Chong WK, Fielding JR, Zou KH,Mittelstaedt CA. Sonographic features ofbenign thyroid nodules: inter-observerreliability and overlap with malignancy. J

Ultrasound Med. 2003; 22:1027-31.

13. Propper RA, Skolnick ML, Weinstein BJ,Dekker A. The non-specificity of thyroid halosign. J Clin Ultrasound. 1980; 8:129-32.

14. Som PM, Curtin HD, Mancuso AA. An

imaging-based classification for the cervical

nodes designed as an adjunct to recent

clinically based nodal classifications” Arch

Otolaryngol. Head Neck Surg. 1999; 125

(4):388-96.

15. Rago T, Vitti P, Chiovato S, et al. Role ofconventional ultrasonography and color flow-

Doppler sonography in predicting malignancy

in “cold” thyroid nodules. Eur J Endocrinol

1998; 1 38:41-46. Abstract

16. Pacella C, Cuglielmi R, Fabbrini R, et al.

Papillary carcinoma in small hypoechoic

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Role of Color Doppler and High Resolution Sonography in the Prediction of Malignant Maksuda Begum et al

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Evaluation of Outcome of Management of Giant

Cell Tumour of Bone by Curettage, Chemical

Cauterization and Morcellized Bone Graft in

Sandwich Technique Augmentation with Bone

CementIMAM GAZIUL HAQUE1, HASAN MASUD2, PROF SK NURUL ALAM3, M SAJJAD HOSSAIN4,

SHAHRYAR NABI5, SHAMIM AHMED6

1. Associate Professor, NITOR, Dhaka, Bangladesh. 2. Associate Professor, NITOR, Dhaka, Bangladesh. 3. Professor

& Ex-Director (RTD), NITOR, Dhaka, Bangladesh. 4. Professor (RTD) NITOR, Dhaka Bangladesh. 5. Assistant

Professor, Department of Radiology & Imaging, Dhaka Medical College. 6. Associate Professor, Department of

Radiology & Imaging, Dhaka Medical College, Dhaka

Abstract:

Of ample of treatment modalities, successfulness

of treatment is based on reduced rate of local

recurrence and gratifying functional outcome of

joints. The virtues of this surgical technique, in

spite of extended curettage and chemical

cauterization are on the use of morcellized graft

and adjuvant bone cement. The bone cement exerts

a) tumerocidal effect by heat dispersion and toxic

free radicals b) provide immediate load bearing

stability and c) easy earlier detection of local

recurrence due to its radio-opaque property. So the

study incorporating this treatment modality reflects

toward the formulation or to validate updated

classic option as well as innovate new avenues of

preferred method of treatment. This descriptive

cross sectional study was conducted in the National

Institute of Traumatology & Orthopaedic

Rehabilitation (NITOR), Sher-E-Bangla nagar,

Dhaka during the period of January 2003 to

December 2004. This study lacks in statistical

significance test due to small sample size and strict

inclusion criteria. In this study, total number of

patient was 11 and mean age was 30.18 years. 07

(63.63%) were female and rest 04 (36.36%) were

male. Most of the tumour was on distal femur

(54.55%) and proximal tibia (36.36%). On

Enneking’s and Campanacci scale stage II disease

was seen in all 11 cases. One patient developed

superficial infection. The outcome of treatment was

categorized using MSTS rating system scale. The

mean follow up time was 8.5 months and one case

was followed up for 24 months, no recurrence was

demonstrated.

Introduction:

Sir Astlay Cooper (in 1981 AD) was the first to

describe the Giant cell tumour and the term was

popularized by Joseph Bloodgood in 1912. Virchow

in 1962 agreed that Giant cell tumour are usually

benign but might recur or become malignant.

Giant cell tumour of bone is a distinct, locally

aggressive primary neoplasm, composed of oval

or plumb spindle shaped mononuclear cells that

fuse to form the giant cells. It is a tumour of

uncertain origin but recent concept is associated

with over expression of osteoprotegerin ligand

(OPGL), stimulator of osteoclast that appear in the

epiphysis of mature bone commonly in the distal

femur proximal tibia, distal radius, proximal

humerus but other bones may also be affected. It

is hardly seen before closure of the epiphysis in

that region and characteristically it extends up to

the subarticular bone plate 1. It is uncommon in

short tubular bones of hands and feet, extremely

rare in vertebral bodies but sacrum is the most

common site in axial skeleton 2. More than half of

the tumours occur about the knee. Giant cell

tumour accounts for only 4-5% of primary bone

tumour in United States and 20% in China.

National Institute of Traumatology & Orthopaedic

Rehabilitation (NITOR), Dhaka reported 17.6% of

primary bone neoplasm from the work-up of

tumour registry 3. In most series, there is female

predominance, though 5 to 75 years of age being

reported; 70% to 80% occurring between the age

of 20 and 40 years 4.

BANGLADESH JOURNAL OF RADIOLOGY AND IMAGING 2014; VOL. 22(2): 88-92

.

Campanacci et al have recently developed similar

staging system based on combined radiographic

presentation and histologic grading that is helpful

in planning the initial surgical approach to any

specific lesion5. There are no such obvious clinical,

radiographic or histologic parameters to predict

the tendency of any lesion to recur or to

metastasize4. They often recur and may become

malignant after unsuccessful surgical removal6.

The Mayo Clinic and Memorial Hospital reported

true malignant Giant cell tumour to be 2.6% &

1.9% respectively7. Secondary malignant Giant cell

tumour, mostly sarcoma viz. Osteosarcoma,

Malignant fibrous histocytoma or Fibrosarcoma

may occur following irradiation4. Recurrence or

more persistence of the lesion usually occurs within

3 years following treatment8.

In the 19th century, routine amputation was theprocedure. But with the advent of surgicaltechniques, curettage alone or with bone graftinghas been reported with local recurrence rate

between 17 - 55%. The recurrence with

cementation is reported to about 8% and Wide

excision or amputation has the recurrence rate of

0-5%.9

Patients & Methods:

Cases were selected with strict inclusion criteria

namely Giant cell tumour located at the end of

tubular bones. Enneking stage II, proved by biopsy

irrespective of age and sex using non-probability

or purposive sampling technique and data were

collected using semi-structured questionnaire and

observation checklist. Collected data were checked

and coded as per required and was analyzed in

computer with the help of statistical package for

social science(SPSS) version 11.2.This particular

descriptive cross sectional study was conducted in

National Institute of Traumatology and

Orthopaedic Rehabilitation during the period of

January ‘2003 to December’ 2004 to evaluate the

outcome of management.

Justification of the Study :

In spite of couples of modalities of surgical

treatment, due to eventual risk of higher rate of

local recurrence, this adequate and efficient

technique tailing the recurrence rate quite reduced

or even to absent making the patient disease free

as well as permit themselves to share toward the

development of national economy and productivity.

So these studies implicate toward the formulation

or to validate optimal treatment protocol, provide

scientific record for further study and in innovation

of new avenues of preferred method of treatment.

Surgical Technique for Study Subject:

Operations are carried out under General and or

spinal anaesthesia with non-Esfnarch tourniquet.

Conventional longitudinal incisions for the affected

site were followed. Wide exteriorization was made

by cortical window through the most lytic and

accessible location. After wide exteriorization and

aggressive curettage, the soft tissue were covered

and protected with Vaseline gauze or saline soaked,

clean, sterile mob.

In the curretted tumour cavity, Hydrogen peroxide

was poured and kept it there up to the period of

end of bubbles emitted. Then it was cleared and

sucked out. The dry tumour cavity was treated

with chemical cauterization by means of sterile

cotton tipped swab stick soaked with 100% phenoland touched it to the exposed bone tumour bedkeeping it there for 20-30 seconds. The blackenedcauterized cavity surface was ringed with 70% ethylalcohol for 3-4 minutes to wash away the phenoland thereafter was sucked out. Vigorous lavage

with copious amount of isotonic saline was done

and was sucked out. Later on, manually made

morcellized autogenous bone graft was laid down,

packed tightly and uniformly on the chondral site

of the cavity. Single layer (3-4 mm thickness) of

gelfoam (spongostan) was then laid down over this,

Gelfoam (spongostan) inserted so (sandwich) in

between graft / cement interface, absorbs heat,

protect the graft. Finally the rest of the cavity was

filled and packed tightly with acrylic cement and

the area was irrigated with normal saline reducing

its local warmth. In all cases, close drain was

inserted on the surface of the bone, were usually

maintained for 3-4 days. The incision was closed,

inner one by delayed absorbable suture (vicryl 2/

0) and the outer skin apposed by monofilament

proline with interrupted stitch without mere

tension. After reconstruction or primary closure,

local skin condition was carefully assayed by its

Evaluation of Outcome of Management of Giant Cell Tumour of Bone by Curettage Imam Gaziul Haque et al

89

colour, circulatory status by needle prick and

documented accordingly.

Post Operative Care: Initially the limb was kept

on long leg posterior plaster slab and on third

generation parental Cephalosporin for subsequent

4-5 days, after that treatment was continued with

oral second generation Cephalosporin. Following

attenuation in drain amount, the tube was

removed usually 4-5 days later with asepsis care.

Limb was kept elevated, muscle building and

stretching exercises were started within the limit

of pain and tender loving care.

Skin stitches were removed on 12-14th post

operative day in all cases of this series, slab was

replaced by cast, and patients were discharged

advising non weight bearing ambulation with

axillary crutch, muscular exercises with

continuation of oral 2nd generation Cephalosporin

for further 3 weeks, advised to attend to follow up

clinic.

Follow up of the Study Subject: Usually the

casts were maintained 6-8 weeks even 10 weeks

depending upon the site and extent of the tumour.

Following removal, gentle active ROM exercises

were advised and continued accordingly. In

addition, patient was also asked to attend the

follow up clinic at 1-2 months interval for the first

6 months and at 3-4 months interval for the next

one year and later was followed at half yearly

interval on the subsequent years, using clinical

evaluation and x-ray findings as tools. Usually local

recurrences appear between 6 months to 3 years

following treatment; so follow up protocol was

scheduled intensely for the first 3 years.

Results: This descriptive cross sectional study was

accomplished to evaluate the outcome of treatment

of giant cell tumor by aggressive curettage,

chemical cauterization, morcellized hone graft in

sandwich technique and augmentation with bone

cement. The study subjects (patients) were treated

in NITOR during the period of January ‘2003 to

December’ 2004. Findings were analyzed based on

dependent and independent variables namely age

and sex distribution, location of the tumour ;

functional outcome were categorized as good, fair

or poor based on complications following surgery

and local recurrence using MSTS scales as with

the assistance of work of Alam10.

Table - I

Age distribution of the patients. (n=11)

Mean age = 30.18 (±SD 10.17) Yrs

Age Group (In yrs) No. of Patients Percentage

16-20 3 27.27

21-30 2 18.18

31-40 4 36.37

41-46 2 18.18

Total 11 100.00

Table - II

Location of Giant Cell Tumour

Site No. of patients Percentage

Distal end of femur 6 54.55

Proximal end of Tibia 4 36.36

Distal end of Tibia 1 9.09

Total 11 100.00

Table -III

Clinical presentation (Sign-Symptoms) of Giant

cell tumour

Clinical presentations No of Percen-

patients tage

Pain 11 100

Enlarging mass 10 90.91

Difficulty in joint motion 8 72,73

Tenderness 6 54.55

Muscle atrophy 4 36.36

Swelling of the adjacent joint 2 18.18

Multiple response

Fig.-1: Pie diagram showing the Post operative

status

Bangladesh Journal of Radiology and Imaging Vol. 22(2): July 2014

90

Table -IV

Final outcome of management of Giant cell tumour

Grade No of patients Percentage

Good 7 63.64

Fair 3 27.27

Poor 1 9.09

Total 11 100.00

Table - V

Distribution of patients by grading of outcome of

management and location of Giant cell tumour

Grading of Location Total

out come Lower end Upper end Lower endof femur of tibia of tibia

Good 4 3 - 7

Fair 1 1 1 3

Poor 0 0 1 1

Total 5 4 2 11

Discussion:

Efficacious treatment of giant cell tumour is based

on adequacy of the removal of tumour and use of

adjuvant to determine local recurrence at earlier.

Above all, the surgical technique is the most

important predictor detecting local recurrence. Nodoubt, early treatment is worthwhile like otherbenign and malignant bone lesions. The goal iscomplete eradication of tumour, preservation ofjoint function as well as salvage of the limb. Theoptimal treatment is a matter of controversy andchoices are versatile but the goal is to reduce therate local recurrence. Out of several modalities,this protocol of treatment is an efficient andoptimal one showing reduced local recurrencewhich is about 8% unlike simple curettage with orwithout bone graft which exhibits local recurrenceof 27 to 50%, and radical excision and amputationrepresenting local recurrence of 0 to 5% 9,11.

So toward planning a treatment protocol, a surgeonmust decide whether to perform intra-lesionalexcision (curettage) salvaging joint and limb orradical excision (Amputation), whether to useadjuvant therapy to eradicate residual microscopic

disease and what material to be used to fill the

resultant defect. The merits of this technique in

respect of superiority are as follows:-

1. Wide extorization making a cortical window

allows complete removal through curettage.

2. Use of 100% phenol during cauterization

coagulates protein, damages DNA.

3. Use of morcellized bone graft (Autogenous +

Allogenic) having reduced bone to bone

interface offers better and early graft

incorporation providing Osteoinductive

stimulous to the chondral site restoring normal

load bearing mechanics.

4. Gelfoam inserted in graft-cement interface

absorbs heat from polymerization of bone

cement protects the chondral graft (morcellized)

from thermal insult. Efficacy of the cement is

not merely filling the defect but also it exerts

tumoricidal effect by heat dispersion, extend

tumour margin clearance by released toxic free

radicals from monomer diffusion. As bone

cement is radiolucent, it facilitates earlier, easy

detection of recurrence. Moreover it provides

immediate mechanical stability and makes the

rehabilitation speedy.

5. Overall functional results were gratifying. Most

of the cases were in the lower femur and upper

end of the tibia 90.91%. In this series, a slight

female predominance though the patients were

from 15 - 50 years of age (Mean age = 30.18yrs).

20 yrs - 40yrs (54.55%) age gr. showed higher

prevalence. In the present study, maximum

follow up was up to 25 months and minimum

of 02 months (mean 8.5 months), but no

recurrence was demonstrated. The weakness

of the study imparted that this was a small

piecemeal study, strict inclusion criteria, the

numbers available were not sufficient to

provide enough power to detect statistical

significance in regard of recurrence between

groups. The data presented here have the

potential to contribute to multi-institutional

studies and meta-analysis. So, in conclusion,

this attempt, a third one can initiate wide

spectrum study in the field of Giant cell tumour

management in future in context of Bangladesh.

Evaluation of Outcome of Management of Giant Cell Tumour of Bone by Curettage Imam Gaziul Haque et al

91

References:

1. Apley AG. Solomon I. 2001. Apliys System of

Orthopaedics and Fractures. 8th edition.

Butterworth - Heinemann Ltd. 175-176.

2. Dorfman, HD.1998. Bone tumour. Mosby inc.

Philadelphia:550.

3. Talukder MS. 1975. Bone Tumor Registry’ in

Bangladesh.

4. Eckrdt, JJ. And Grogan, TJ. 1986. Giant Cell

Tumor of Bone. Clinical orthopaedics and

related research, 204. 45 –57.

5. Campanacci, M. Baldini, N. Boriani, S. and

Sundnese. A. 1987. Giant Cell Tumour of

Bone. The journal of bone and joint surgery,

69(A):ppl06-l 13.

6. Turek, SL. 1984 Orthopaedic Principles and

Their Applications. 4th ed., J.B. Lippincott

Company, Philadelphia, Vol-1 611-638.

7. Cooper, KL. Eckrdt. JJ, Unni, KK And Sim,

HI. 1980. Mam Clinic tumour rounds. BenignGiant Cell Tumor of Bone, 3(11): 142-1148.

8. Carnesale, PC. 1992. Malignant Tumors ofBone. Cambell’s Operative Orthopaedics. 8lh

edn, Vol.1.253-256.

9. Stefano, A. Bini, MD. Kan Gill, MD. AndJames. O. Johnston, MD. 1995. Giant CellTumor of Bone-curettage and cementreconstruction. Clinical Orthopaedics and

related research* 32 K 245-250.

10. Alam. SN. 1985. Evaluation of the Result ofOperative Treatment of Giant Cell Tumourof Bone. The journal of Orthopaedic Society

oj Bangladesh. 20:23-57.

11. Blackle. HR. Wunder, JS. Davis, AM. White,LM. Kandel, R. and Bell, RS. 1999. Treatmentof Giant-Cell Tumors of Long Bones withCurettage and Bone-Grafting. The Journal of

bone and joint surgery, 81 (A), 6:pp. 811-820.

Bangladesh Journal of Radiology and Imaging Vol. 22(2): July 2014

92

Abstract:

Macrodystrophia lipomatosa is a rare cause of

congenital macrodactyly. It can be confused with

other common causes like congenital lymphedema.

Usually it presents with loss of function and

cosmetic problems.

We here report a case of “Macrodystrophia

lipomatosa” who attended Dhaka medical college

hospital with progressive disproportionate

enlargement of the middle finger of right hand.

She underwent debulking operation twice. The

patient had no pain or neurovascular symptoms

and there was no family history of extremity

gigantism. Plain radiograph demonstrated splayed,

elongated, broadened phalanx with soft tissue

swelling along the volar and dorsal aspect of middle

finger of right hand, along with palmer angulation

of that finger. MR images revealed proliferation of

fatty tissue in the same areas, as seen in plain

radiograph with signal intensity similar to that of

subcutaneous fat. Histopathology revealed

abundant adipose tissue with some interspersed

fibrous tissue.

Keywords: Macrodystrophia lipomatosa(MDL).

Macrodactyly.

Introduction:

Macrodystrophia lipomatosa is a rare cause of

congenital macrodactyly, characterized by

progressive proliferation of all mesenchymal

elements with a disproportional increase in fibro

adipose tissue1. Almost always unilateral and can

involve both the upper extremities (usually in the

distribution of the median nerve with the index

and middle fingers most commonly involved) and

CASE REPORTS

Macrodystrophia Lipomatosa - Case ReportFONINDRA NATH PAUL1, MOHAMMAD MIZANUR RAHMAN2, MD ANISUR RAHMAN KHAN3,

DOSTH MOHAMMAD LUTFUR RAHMAN4, ZANNATUL FERDOUS5

1. Junior Consultant, Department of Radiology & Imaging, TB Hospital, Shyamoli, Dhaka. 2. Professor and Head

of Department of Radiology & Imaging, Dhaka Medical College. 3. Assistant Professor, Department of Radiology &

Imaging, DMC. 4. Junior Consultant, Department of Radiology & Imaging, 500 bedded General Hospital, Dhaka.

5. Radiologist, Dhaka Medical College & Hospital

in the lower extremities (usually in the distribution

of planter nerve)2,3. Though the exact etiology of

MDL is not known, various hypothesis exist,

including alteration of somatic cells during limb

bud development, disturbed fetal circulation,

variable form of neurofibromatosis, lipomatous

degeneration, trophic influence of tumified nerve,

in utero disturbance of growth limiting factor or

an error in segmentation. It is usually diagnosed

at birth or during the neonatal period1,2,4.

Case report:

An 11 years old right hand dominant female child

was referred to radiology department for X-ray of

right hand because of excessive growth of her

middle finger that had enlarged gradually since

birth. She had undergone two operations to debulk

the lesion. The patient denied having any pain or

neurovascular symptoms and there was no family

history of extremity gigantism. On physical

examination, non-tender, disproportionately

enlargement of middle finger was found. There

was no overlying cutaneous change, pitting edema

or bruit. The patient was able to use the hand well

and had adequate grip. A plain radiograph

demonstrated splayed, elongated, broadened

phalanx with soft tissue swelling along the volar

and dorsal aspect of middle finger of right hand,

along with palmer angulation of that finger.

Extraction of fat was done through an incision

placed over the dorsum of the middle finger.

Pathological examination of the material revealed

abundant adipose tissue with some interspersed

fibrous tissue.

BANGLADESH JOURNAL OF RADIOLOGY AND IMAGING 2014; VOL. 22(2): 93-95

Both T1W andT2W MRI images revealed

proliferation of fatty tissue on the volar and dorsal

aspect of the middle finger with signal intensity

similar to that of subcutaneous fat with palmer

angulation of the affected digit.

Discussion:

Macrodystrophia lipomatosa (MDL) is uncommon,

congenital, non hereditary localized gigantism

involving usually 2nd or 3rd digits of hand or foot

corresponding to the median and medial planter

nerve supply upper and lower limb respectively5.

Occasionally it involved the entire limb.

Macrodystrophia lipomatosa, this term was first

used by Feriz in 1925 to describe unilateral

overgrowth of the lower limb1. In 1967 Barsky

described it is worth nothing that MDL is

essentially analogous to static localized gigantism5.

Though the exact etiology of MDL is not known,

various hypothesis exist, including alteration of

somatic cells during limb bud development,

disturbed fetal circulation, variable form of

neurofibromatosis, lipomatous degeneration,

trophic influence of tumified nerve, in utero

disturbance of growth limiting factor or an error

in segmentation. It is usually diagnosed at birth

or during the neonatal period 1,2,4.

MDL is characterized by a marked increase all

mesenchymal elements. This is dominated by

adipose tissue in a fine network involving

periosteum, bone marrow, nerve sheath, muscle

and subcutaneous tissue1. It is usually presents at

birth and recognized associated anomalies include

syndactyly, polydactyly, brachydactyly or

clinodactyly. Association with small osseous

protuberance, which resembles osteochondromas

and lipoma in other parts of the body, has also

been reported. The disease is almost always

unilateral, with an equal incidence in males and

female. The growth velocity may differ from digit

to digit and the abnormal growth usually ceases

at puberty. The lower extremity is frequently

involved than upper extremity. The abnormal area

is usually along a specific sclerotome1,5.

Different imaging modalities such as plan

radiography, USG, CT scan and MRI have a rolein the evaluation of MDL. Plain radiographyusually suffices and demonstrates splayed,lengthened and broadened phalanges called

mushroom like appearance with periosteal and

endosteal bone deposition1,5. The overlying soft

tissues are markedly overgrown and within the

soft tissues focal lucent areas representing fat may

be seen, which is characteristic1,6. Both USG and

CT scan can be used to demonstrate the

proliferation of the fat along the nerve territory1.

MRI easily demonstrates the excessive fibro fatty

tissue, which has signal characteristics similar to

X-ray hand shows

elongated, Broadened,

Splayed Phalanges with

surrounding excessive soft

tissue shadow of middle

finger.

Photograph of right hand shows

soft tissue swelling causing

enlargement of middle finger

(local gigantism).

Sagital T1W MRI image reveals

proliferation of fatty tissue (arrows)

on the volar aspect of the middle

finger with signal intensity similar to

that of subcutaneous fat; there is

palmer angulation of the affected digit.

Bangladesh Journal of Radiology and Imaging Vol. 22(2): July 2014

94

subcutaneous fat that is high signal on T1W,

intermediate signal on T2W and low signal on fat

suppressed sequences. The fat in MDL is not

encapsulated. The fibrous strands within the fatty

tissue are seen as low signal intensity linear

strands on T1W images1.

Histopathology shows an abundant increase in

adipose tissue scattered in fine, mesh like fibrous

tissue7.

Differential diagnosis includes (a) Neuro-

fibromatosis, (b) Fibrolipomatous hamartoma of

the median or ulnar nerve, where fatty tissue

accumulates within nerve sheath rather than in

the region, (c) Vascular malformation like

Haemangioma including Maffucci syndrome,

arterio-venous malformation (AVM), Klippel-

Trenaunay-weber syndrome, (d) Chronic

hyperaemia as in Juvenile rheumatoid arthritis,

haemophilia, (e) Hemi-hypertrophy as in Beckwith

Wiedemann syndrome and (f) Russel-Silver

dwarfism5.

Although MDL is considered a progressive form of

macrodactyly (i.e. the growth of the affected parts

is faster than the rest of the body) the growth halts

at puberty5. Surgical intervention is the treatment

of choice for MDL. The main surgical principle of

treating these lesions is to improve the cosmetic

appearance while preserving the neurological

function as much as possible. Through judicious

and planned multiple debulking operations and

partial amputations, good results can be achieved.

However, surgery should be delayed until the

patient’s growth is complete, if the deformity is

not very serious and if no neurological symptoms

are present1.

Complications of MDL include mechanical problems

secondary to degenerative joint disease, or

neurovascular compression due to large

osteophytes. Overzealous debulking procedures

can also lead to nerve injury, the reported incidence

ranged from 30% to 50%. A localized recurrence

rate is about 33% to 60% 1,7.

Conclusion:

MDL is progressive hamartomatous enlargement

of the fibro fatty tissue involving all the layers of

soft tissue. The purpose of this case report is to

create awareness that MDL should be considered

in the differential diagnosis of progressive

disproportionate enlargement of a finger. Plain

radiography usually suffices. Both USG and CT

scan can be used to demonstrate the proliferation

of the fat along the nerve territory. MRI easily

demonstrates the excessive fibro fatty tissue and

the fibrous strands within.

The diagnosis of the above described case is

accomplished on the basis of clinical presentation

and imaging findings on X-ray and MRI.

References:

1. V. Singla, V Virmani, P Tuli, P Singh and N

Khandelwal. Case report: Macrodystrophia

lipomatosa-Illustration of two cases. Indian

J Radiol Imaging. Nov 2008; 18(4):298-301.

2. http://en.wikipedia.org/wiki/Macrodystrophia

lipomatosa.

3. Bailey EJ, Thompson FM, Bohne W, Dyal C.

Macrodystrophia lipomatosa of the foot: a

report of three cases and literature review.

Foot ankle Int. 1997 Feb; 18(2):89-93.

4. AB Goldman and JJ Kaye: macrodystrophia

lipomatosa: Radiographic Diagnosis Am. J.

Roentgenology, Jan 1977; 128(1): 101-105.

5. http://radiopedia. Org/articles/ macrody-

stropha-lipomatosa.

6. Rizwan a Khan, Shagupta Wahab, Ibne Ahmed

and Rajendra S Chana.macrodystrophi

lipomatosa: four case reports: Indian Journal

of Pediatrics 2010, 36:69 doi: 10. 1186/1824-

7288-36-69.

7. Jae Hyun Kwon, So Young Lim, and Ha Seong

Lim. Macrodystrophia lipomatosa: Arch Plast

Surg. May 2013; 40(3):270-272.

Macrodystrophia Lipomatosa - Case Report Fonindra Nath Paul et al

95

Abstract

The polysplenia syndrome (PSS) is a form of situs

ambiguous with multiple spleen, cardiac anomalies,

abdominal heterotaxia, short pancreas, major

venous system and bronchial malformations. It is

a rare syndrome, more often found in childhood,

and only the 10% of the patients that do not have

cardiac anomalies can reach adulthood. Isolated

polysplenia is rather exclusively rare having no other

associated anomaly but multiple spleen. We present

a 52 year old male patient with low grade fever

and mild abdominal pain, who was referred to

Radiology & Imaging Department for USG of whole

abdomen from Out Patient Department. In USG

no single spleen was found; rather multiple soft

tissue masses having echo texture comparable with

spleen were identified in the splenic fossa. A

confirmatory CT scan was performed and

polysplenia was diagnosed. To exclude any

associated anomaly echocardiogram and CT scan

of chest were performed. As no other anomaly was

detected the final diagnosis was made as a case of

isolated polysplenia.

Key words: Polysplenia, splenic nodules, USG,

CT scan.

Introduction

Isolated polysplenia is the single entity that

describes the presence of multiple aberrant splenic

nodules without any associated organic

malformations .Whereas, the polysplenia syndrome(PSS) is a type of situs ambiguous characterized

by left isomerism1,2, conformed by a group of

visceral anomalies of unknown etiology, in which

the presence of multiple aberrant splenic nodules

and wide range of organic malformations exist.

Helwig is credited with describing the Heterotaxia

(polysplenia) syndrome in 1929.The abnormalities

Isolated Polysplenia in Adult Patient – A Case

Report with Review of the LiteratureASHRAF UDDIN KHAN1, MARIYAM SULTANA2, SHIBENDU MAJUMDER3

1 Assistant Professor, Department of Radiology & Imaging, Shaheed Suhrawardy Medical College and Hospital

(ShSMCH). 2 Medical Officer, Department of Radiology & Imaging, Dhaka Medical College Hospital 3. Professor &

Head of department of Radiology & Imaging, Shaheed Suhrawardy Medical College and Hospital (ShSMCH).

that integrate the PSS are wide3; the most constant

– in addition to the polysplenia – are cardiac

malformations, thickening and interruption of the

vena cava, along with abdominal heterotaxia.

Although its presentation is less constant, the

presence of a short pancreas and genitourinary

malformations has also been described. It is a

frequent alteration that is detected mainly in

childhood, 40% of the affected patients reach 2

years of age and the majority dies before the 5th

year4. 5 to 10% lack cardiac involvement, which

allows them to reach adulthood5.

Case report

A 52 year old male, non diabetic, non hypertensive

presented with a 10 days history of low grade fever

and mild abdominal pain in medicine OPD. On

examination no organomegaly was found.

Abdomen was soft and non-tender. No respiratory

distress or palpitation was present. The patient

was referred to Radiology & Imaging Department

for USG of whole abdomen.

In USG no single spleen was found; rather five

soft tissue masses having echotexture comparable

with spleen was identified in the splenic fossa. Each

splenic nodule revealed its own hilum, having

separate artery and vein; confirmed by Color

Doppler. No abdominal lymph-adenopathy was

seen. Abdominal aorta and IVC were in normal

position and appearance. Liver was found in normal

position and echotexture. No sign of any other

organic malformation or heterotaxia was seen.

Confirmatory CT scan was performed and about

five splenic nodules were found in splenic fossa.

Axial and reconstruction sagittal, coronal images

are shown here (figure 1, 2, 3)

BANGLADESH JOURNAL OF RADIOLOGY AND IMAGING 2014; VOL. 22(2): 96-99

Fig.-1 : Axial images

Fig.-2: Sagittal images

Fig.-3 : Coronal images

Fig.-34 : B-mode showing splenic nodules F-5: Color Doppler showing splenic hilar vessels

Isolated Polysplenia in Adult Patient – A Case Report with Review of the Literature Ashraf Uddin Khan et al

97

Single splenic artery arising from abdominal aorta

was found to be branched to give supply in each

splenic nodule, which is evident in USG with Color

Doppler (Fig.- 4)

Thus polysplenia was diagnosed.

Then the patient was advised for echocardiogram

and chest CT scan to explore any other associated

abnormality. Echocardiogram showed normal

findings. No evidence of any congenital or acquired

anomaly was seen.

Chest CT scan showed no aberrant lobe or fissure.

No obstructive or inflammatory or neoplastic

lesion was seen. The case was finally categorized

as isolated polysplenia, as no other organic

malformation could be identified other than

multiple splenic nodules.

Discussion

Usually polysplenia demonstrates as a rare

syndrome involving multiple organ malformation.

According to literature the PSS is a congenital

abnormality usually diagnosed in the childhood

stage because almost half of the cases (41%) display

serious cardiac abnormalities which are frequently

fatal, being the most frequent ones interauricular

and/or interventricular communication,

transposition of great vessels, stenosis or

pulmonary atresia and dextrocardia4,5.

Since 5 to 10% of the cases lack cardiac damage or

only present a small alteration, it allows the

patients to reach adulthood5. PSS in the adult

produces unclear manifestations; the presence of

polysplenia, situs ambiguous or situs inversus

(21%) is enough to establish the diagnosis1,2,3;

which is generally unsuspected and thus fortuitous

in nature2,3.

The case we presented here has the characteristics

of only one organ malformation that is the

polysplenia. The unique sign of the isolated

polysplenia is the presence of multiple spleens,

ranging from 2 to 16. Five splenic nodules were

found in this case primarily located throughout

the superolateral aspect of left kidney.

Among the vascular anomaly hypoplasia of the

inferior vena cava with absence of its intrahepatic

segment is described6.

The cardiovascular system is the part of the fetal

anatomy that most frequently suffers from

congenital pathology7.A wide range of cardiac

anomaly including hypoplastic left heart syndrome,

tricuspid atresia, single ventricle, transposition of

great arteries, interruption of the aortic arch,

double aortic arch, right-sided aortic arch etc are

described. However in our case no cardiac anomaly

was detected, most fortunate for the patient.

When the alteration involves the pancreas, a

diminution in its dimensions takes place (short

pancreas)8,9,10. By USG and CT scan all of these

anatomical alterations are excluded. The other

alterations include the development of bilateral

lobulated lungs (60%) and genitourinary

malformations like renal agenesis, hypoplastic

kidneys, and duplication of thex collector collecting

systems, which were luckily absent in this case.

The malformations of our patient were limited to

the spleen, which is not symptomatic. This makes

a good result for the patient in the medium to long

term with a favorable prognosis.

References

1. Vaughan TI, Hawkins LP, Elliot LP.

Diagnosis of polysplenia syndrome. Radiology

1971; 101: 511-518.

2. Gayer G, Apter SS, Jonas T, et al. Polyspenia

syndrome detected in adulthood. Report of

eight cases with review of the literature.

Abdominal Imaging 1999; 24: 178-184.

3. Vossen PG, Van Hedent EF, DegryseHR ,et

al. Computed tomography of the polysplenia

syndrome in the adult. Gastrointestinal

Radiology1987; 12: 209-211.

4. Mclhenny. Biliary atresia and polysplenia

syndrome.AJR 1996: 271-272.

5. Abramson SJ, Berdon WE, Altman RP, et al.

Biliary atresia and non cardiac poli-splenic

Bangladesh Journal of Radiology and Imaging Vol. 22(2): July 2014

98

syndrome: US and surgical considerations.

Radiology1987; 163: 377-379.

6. Ito K, Matsunaga N, Mitchell D, et al. Imaging

of congenital abnormalities of the portal

venous system. AJR 1997; 168: 233-237.

7. Chiappa E. The impact of prenatal diagnosis

of congenital heart disease on pediatric

cardiology and cardiac surgery. J Cardiovasc

Med 2007; 8:12–6.

8. Sener RN, Alper H. Polysplenia syndrome: A

case associated with transhepatic portal vein,

short pancreas anf left inferior vena cava withhemiazygous continuation. Abdominal

Imaging 1994; 19: 64-66.

9. Hadar H, Gadoth N, Herskovitz P, et al. Shortpancreas in polysplenia syndrome.ActaRadiol1991; 32: 299-301.

10. Herman TE, Siegel MJ. Polysplenia syndromewith congenital short pancreas. AJR 1991;156: 799-800.

Isolated Polysplenia in Adult Patient – A Case Report with Review of the Literature Ashraf Uddin Khan et al

99

Abstract:

Carotid Carvernous Fistula (CCF) is an abnormal

communication between the internal or external

carotid arteries and the cavernous sinus. Abnormal

communications may occur due to traumatic or

spontaneous etiology. This results in the short

circuiting of the arterial blood with the venous

system of the cavernous sinus. Direct CCF

represents 70-90%. Dural carotid cavernous fistula

occurs commonly in middle aged to elderly women.

Traumatic carotid cavernous sinus fistula occurs

more commonly in young individual. Nearly all

patients experience progressive occular

complications. A 39 years old lady presented with

protrusion & redness of right eye ball and swelling

of eyelids. She also had complaints of visual

disturbance and headache for 08 months. She had

history of HTN. She was 4th gravida. She

developed all her signs and symptoms while she

was 6 months pregnant and gave birth to a male

baby few months back but her complaints still

persisted.

Imaging studies: CT and MRI of brain and eye

ball were done and she was suspected of having

carotid cavernous fistula on right side. The

definitive diagnostic modality is cerebral angiogram

with selective catheterization of the internal &

external carotid arteries on both sides. Diagnosis

was confirmed and all vascular contributions to

the fistula were visualized. Immediately medical

treatment was started but definitive surgical

treatment was yet to start.

Introduction :

Carotid carvernous fistula (CCF) is abnormal

communications between the carotid arterial

system and the carvernous sinus. They can be

spontaneous or acquired. Classified as direct or

indirect1. Direct CCF represents 70-90% of all

cases. Dural carotid carvernous fistula commonly

occurs in the middle aged to elderly women, while

traumatic carotid cavernous sinus fistula occurs

Carotid Cavernous Fistula (CCF): A Case ReportSYED ZOHERUL ALAM

Classified specialist in Radiology & Imaging, CMH, Dhaka.

commonly in young individual2. Spontaneous direct

CCF is often associated with underlying collagen

defiencies, such as Ehlers-Danlos syndrome3.

CT and MRI are useful in assessing the degree of

associated cerebral parenchymal injury, oedema

and orbital changes. Digitally substracted

angiography is pivotal in characterizing the

vascular abnormality, diagnosis and guiding the

endovascular treatment.

Case Report:

Mrs Rina Akter of 39 years old, hailing from

keraniganj, Dhaka was admitted in Bangabandhu

Sheikh Mujib Medical University(BSMMU) with

the complaints of protrusion, redness and visual

disturbance of right eye and headache for 8

months. She was also suffering from

hypertension. All her signs and symptoms

gradually started while she was 6 months

pregnant. She gave birth to a normal baby 2

months back but her complaints still persisted.

She was obese and nondiabetic. Her biochemical

and haematological profiles were almost within

normal limit at the time of examination except

raised blood sugar.

Fig.-1

BANGLADESH JOURNAL OF RADIOLOGY AND IMAGING 2014; VOL. 22(2): 100-102

CT scan and MRI of brain / orbit were done whichshowed suspected right sided carotid carvernousfistula with adjacent engorged vessels andproptosis of right eyeball. No bony lesion could bedetected in the skull base or orbit.

Angiogram findings: Dilated pool of contrast was

found in the cavernous part of right internal carotid

artery (ICA), from there dilated and tortuous right

superior ophthalmic vein and other abnormal

engorged vessels were visualized. Cerebral

branches of right ICA was deficit, rather right ACA

and MCA were visualized from opposite side i.e

when catheter was introduced on left side. Jugular

venous channels were visualized in arterial phase.

Renal angiogram was also done as she was having

high blood pressure but renal angiogram was found

normal.

So diagnosis was confirmed after carotid and

cerebral angiogram. Extension and vascular

contributions were also detected from angiogram.

Discussion:

CCF results in short circuiting of the arterial blood

with the venous system of cavernous sinus.

Angiographically Barrow classified CCF into four

types: Type A, a direct shunt between the intra

cavernous part of internal carotid artery (ICA) and

Fig.-2

Fig.-3

Fig.-4

She was sent in cath lab of CMH Dhaka forcerebral and carotid angiogram, to confirm thediagnosis and to find out the extension andcontribution of the vessels. Vascular entry was

right femoral artery (RFA) and catheter used 6

FR, JR-4. During the procedure, in the angiogram

suite, patient was having high blood pressure (160/

110 mmHg) and she was given antihypertensive

drugs (Tab. Amdocal and nificap).

Fig.-5

Carotid Cavernous Fistula (CCF): A Case Report Syed Zoherul Alam et al

101

the cavernous sinus: Type B, a dural arteriovenous

fistula (AV) supplied by the ICA; Type C, a dural

AV fistula supplied by the external carotid artery

(ECA) ; and Type D, a dural AV fistula supplied by

both ICA and ECA. Types B, D and C are often

grouped under the common definition of dural or

indirect carotid cavernous fistulas. Indirect fistulas

are often low flow lesions whereas direct fistula

demonstrate high flow4.

The most frequent cause of direct CCF is (a)

trauma, which accounts for 70-90% of cases (Motor

vehicle accidents, falls or penetrating injury) (b)

Iatrogenic injury may also occur during carotid

angioplasty, trans-sphenoidal hypophysectomy andnasopharyngeal biopsies, (c) Spontaneous directCCF, are often associated with underlying collagendeficiencies such as Ehlers Danlos syndrome.Indirect types (Barrow types B, C and D) are AVfistulas located within the dura surrounding the

cavernous sinus and result from spontaneous

rupture of small dural arteries. Most frequently

in middle aged women, secondary to hypertension

or hormonal factors associated with pregnancy or

menopause5.

Patient of CCF may present with following occular

complaints: Red eye, diplopia, bruit, decreased

vision, bulging eye and facial pain in the

distribution of the first division of the trigeminal

nerve6.

Various diagnostic methods have been described

for CCFs. CT scan, magnetic resonance imaging

(MRI) and orbital echography often help to confirm

the diagnosis, demonstrating extraocular muscle

enlargemant, dilatation of one or both superiopr

ophthalmic veins and enlargemant of the affected

cavernous sinus. Definitive diagnostic test is

cerebral angiography with selective catheterization

of the internal and external carotid arteries on

both sides. Cerebral angiography is the modality

which can show all arterial contributions to the

fistulae. DSA mode is preferable for angiography.

Management of a case of CCF requires medical

and surgical care. Currently, most CCF, direct or

indirect, is treated by endovascular techniques.

Indications for surgical intervention are rare. Both

transarterial and transvenous endovascular routes

may be used to treat direct (type A) CCFs. While

in indirect fistulas (type B, C and D) are more often

managed with transvenous techniques7.

Conclusion:

Catheter angiogram is the best diagnostic test for

CCFs. Early proper diagnosis and prompt minimal

invasive endovascular procedure can reverse the

condition, so that a patient can again see the

horizon; sunrise or sunset.

References

1. Harish stownkeer, Carotid cavernous fistula,

Pathogensis and routes of approach of

endovascular treatment, skull base, 2001,

11(3): 207-218

2. Hirai T, Korogi Y, Baba Y, et al. Dural carotidcavernous fistulas : role of conventionalradiation therpy-long-term results withirradiation, embolization or both, Radiology

1998; 207:423-430

3. Barrow DL, Spector RH,Baraun IF, et al.Classification and treatment of spontaneouscarotid cavernous sinus fistulas. J Neurosurg

1985;62:248-256

4. Kupersmith MJ, Satterfield D, Dublin AB, et

al. Dural and carotid cavernous sinus fistulas:

diagnosis, management and complications.Ophthalmology 1987;94:1585-1600

5. Katsiotis P, Kiriakopolous C, Taptas J.

Carotid-cavernous fistulae and dural arterio-

venous shunts. J Vasc Surg 1974;8:60-69

6. Irgrid U scalt, Carotid cavernous fistula;Medscape: 2012, 17/1/12-i-net.

7. Anne G osborn; Diagnostic Neuroradiology;

1994;1:238-239.

Bangladesh Journal of Radiology and Imaging Vol. 22(2): July 2014

102

Abstract

Neurofibromas are peripheral nerve sheath

neoplasms usually benign but can undergo

malignant transformation when associated with

NF-1. We are reporting a case of orbital plexiform

neurofibroma in an 11-month-old boy who

presented with a painless, gradually increasing

bluish lump on right upper eyelid since birth, which

had a “bag of worms” consistency and slight

proptosis of right eye. CT scan and MRI of brain &

orbit were done to make the diagnosis.

Introduction

Neurofibromas are peripheral nerve sheath neoplasmsderived from a combination of Schwann cells, axons,perineural cells and fibroblasts interspersed withcollagen and a myxoid matrix sometimes in associationwith NF-11. They can manifest within the orbit, andthey may or may not be associated with systemicneurofibromatosis. Neurofibromas, relativelyuncommon orbital lesions, represent approximately2-4% of orbital tumors. Plexiform neurofibromasaccount for 2%, and localized neurofibromas accountfor 1% of all neurofibromas.2, 3

Case Presentation

Master Tahsin, an 11-month-old boy from Dinajpur

presented to Radiology & Imaging department of

Orbital Plexiform Neurofibroma – A Case ReportZINAT NASRIN1, ABUL KHAIR AHMEDULLAH2, FONINDRA NATH PAUL3

1.Junior consultant, National Institute of Ophthalmology & Hospital, Sher-E-Bangla Nagar, Dhaka. 2. Assistantprofessor (Rheumatology), Bangabondhu Skeikh Mujib Medical University. 3. Junior consultant, 250 beded TB

hospital, Shamoly, Dhaka.

National Institute of Ophthalmology & Hospital

with complaints of painless swelling on right upper

eyelid since birth. It presented as a bluish lump

which was gradually increasing in size. He was

otherwise well. His father is a known case of

neurofibromatosis type I. On examination, there

was a soft tissue mass in the right superior-lateral

orbital margin which had a “bag of worms”

consistency on palpation. There was slight

proptosis of right eye but no visual impairment

was evident. On fundoscopy, there were no retinal

folds and the optic discs were normal. Slit lamp

examination was normal. CT scan and MRI of brain

& orbit were done as routine investigation. The

case was clinically diagnosed as orbital plexiform

neurofibroma. Excision biopsy & histopathology

were planned to confirm the diagnosis which is

yet to be performed.

Radiological Findings

CT scan of brain & orbit revealed enlarged rightorbit & slightly proptotic globe. The optic nervewas thickened & irregular in its whole length.Extraocular muscles (superior & lateral rectus)were also thickened. Superior orbital fissure was

widened. Mild peri-orbital soft tissue swelling was

also noted.

Fig.-3: Axial CT scan of brain &

orbit showing thickened optic

nerve & heterogeneous mass in

right temporal fossa.

Fig.-1: Photograph of patient

having orbital plexiform

neurofibroma (right)

Fig.-2: Axial CT scan of orbit

showing enlarged, proptotic

right globe & thickened

extraocular muscles.

BANGLADESH JOURNAL OF RADIOLOGY AND IMAGING 2014; VOL. 22(2): 103-106

.

MRI revealed enlarged right globe with lobulated

ill-defined soft tissue mass extending from anterior

aspect of globe to apex, involving extra & intraconal

space of right orbit & also having extension into

the right temporal fossa through the widened

Superior orbital fissure . The right optic nerve was

thickened & irregular in its whole length. Superior

rectus, lateral rectus and preseptal space of upper

lid were thickened. The lesions were isointense in

T1-weighted images and heterogeneously

hyperintense signal in T2-weighted images. After

i.v contrast no significant enhancement was noted.

Discussion

Plexiform neurofibromas occur in about 60% of

neurofibromatosis type 1(NF-1) patients and can

lead to severe morbidity by disfigurement or

compression of vital structures. Moreover, these

tumors can undergo malignant transformation.

Neurofibromas may broadly be classified as

plexiform, diffuse, or localized tumors.

Plexiform Neurofibromas: Plexiform

neurofibromas are the most common subtype

encountered in the orbit and are closely associated

with Neurofibromatosis type 1 (NF-1). Some

Fig : 4 & 5: Axial T2W MRI: showing heterogeneous mass in right

retro-orbital space with extension into right temporal fossa.Fig: 6 Coronal T1W MR Image

showing thickened extra-ocular

muscles

Fig : 7 & 8: Sagittal T1 & T2W MRI: showing thickened right optic nerve and superior rectus muscle.

Bangladesh Journal of Radiology and Imaging Vol. 22(2): July 2014

104

authors consider these tumors to be

pathognomonic for NF1, though case reports of

orbital plexiform neurofibomas in the absence of

other findings suggest that these lesions may

instead be highly suggestive of the diagnosis4, 5.

They typically present early in life and appear

clinically as infiltrative, multi-nodular masses

growing along the course of peripheral nerves.

Like diffuse neurofibromas, they are typically

poorly circumscribed and vascular.1 Classic

characteristics include a “bag-of-worms”

consistency and eyelid involvement producing an

S-shaped mechanical ptosis (deformity).

Approximately 20% of tumors associated with NF1

may undergo malignant transformation.2

Diffuse Neurofibromas: A more recently

recognized variant similar to plexiform

neurofibroma, diffuse (or diffuse

plexiform) neurofibroma is vascular, infiltrative in

nature, and presents early in life. Diffuse

neurofibromas demonstrate infiltration into the

subcutaneous fat leading to a distinct clinical

appearance of dermal and subcutaneous

thickening. They are thought to be congenital,

though they may not be apparent at birth. Diffuse

neurofibromas are associated with NF1 in at least

10% of cases.6,7

Localized Neurofibromas: Localized (or isolated)

neurofibromas are focal, well-circumscribed

neoplasms that typically present in the superior

orbit during the third to fifth decade of life with a

slowly progressive mass effect.4 They most

frequently involve branches of the frontal nerve.3

11-28% of patients with localized neurofibromas

have a family history or systemic signs of NF1.1

In the absence of NF1, they only rarely undergo

malignant degeneration.8 These tumors are less

vascular than plexiform and diffuse neurofibromas,

and they can often be differentiated from plexiform

and diffuse lesions by imaging studies. The

occurrence of multiple localized neurofibromas has

been reported and may represent a “form fruste”

NF1.4

Plexiform neurofibromas are almost always

associated with NF1, whereas localized

neurofibromas are associated with NF1 in a

minority of cases.  NF1 is a neurocutaneous

disorder that affects 1 in 3000 individuals and is

characterized by multiple café au lait spots and

cutaneous neurofibromas. It is inherited in an

autosomal dominant fashion, although 50% of cases

may be sporadic, and has been mapped to a gene

locus on chromosome 17q11.2.9

Management

Plexiform neurofibromas are more difficult to

remove because of their relative vascularity and

lack of clear margination. Removal may be

complicated by subtotal resection, and recurrence

or re-growth is common3.Large lesions may

ultimately require exenteration.2

Prognosis

Neurofibromas in the setting of NF1 develop

malignant transformation in 20% of cases2 and

require routine monitoring. In the absence of NF1,

localized neurofibromas rarely undergo malignant

transformation, but recurrence has been

occasionally reported following surgical removal.1

Patients should be advised to have routine follow

up with their ophthalmologist. With the

advancement in technology, the management

should depend on the clinical features and the

extent of involvement.

References

1. Gunkel AR, Freysinger W, and Thumfart WF;

“Experience with various 3-dimensional

navigation systems in head and neck surgery,”

Archives of Otolaryngology, 2000, vol. 126,

no. 3, pp. 390–395.

2. Karcioglu Z. Clinicopathologic Correlates in

Orbital Disease. Duane’s Foundations of

Clinical Ophthalmology, 2006, Vol 3, Chapter

17. Lippincott Williams & Wilkins.

3. Misra S. Recurrent neurofibroma of the orbit.

Australas Med J. 2013 Apr 30; 6 (4):189-91.

4. Savar A and Cestari DM, “Neurofibromatosis

type I: genetics and clinical manifestations,”

Seminars in Ophthalmology, 2008, vol. 23 (1),

pp. 45–51.

5. M. D. Poole, “Experiences in the surgical

treatment of cranio-orbital neuro-

Orbital Plexiform Neurofibroma – A Case Report Zinat Nasrin et al

105

fibromatosis,” British Journal of Plastic

Surgery, 1989, vol. 42, no. 2, pp. 155–162.

6. I.T. Jackson, A. Carbonnel, Z. Potparic, and

K. Shaw, “Orbitotemporal neurofibromatosis:

classification and treatment,” Plastic and

Reconstructive Surgery, 1993, vol. 92, no. 1,

pp. 1–11.

7. G. B. Krohel, P. N. Rosenberg, J. E. Wright,

and R. S. Smith, “Localized orbital

neurofibromas,” American Journal of

Ophthalmology, 1985, vol. 100, no. 3, pp. 458–

464.

8. M. H. Erb, N. Uzcategui, R. F. See, and M.

A. Burnstine, “Orbitotemporal neuro-

fibromatosis: classification and treatment,”

Orbit, 2007, vol. 26, no. 4, pp. 223–228.

9. ht tp : / /www.uptodate . com/contents /

n e u r o f i b r m a t o s i s - t y p e - 1 - v o n -

recklinghausens.

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