This  is a lateral Carotid Angiogram of a 17 year old boy who came  to the neurology clinic complaining of left sided  dull headache.And he has had two episodes of tingling sensation of his right arm.His  neurological examination was unevntful.


What is your diagnosis?


ANSWER

ARTERIOVENOUS MALFORMATION IN THE ANTERIOR CEREBRAL TERRITORY


Arteriovenous Malformation are lesions of the cerebral vasculature development such that blood flows directly from the arterial system to the venous system without passing through a capillary system.


The direct AV connection exposes the venous system to abnormally high pressures. This results in a system of enlarged feeding vessels, the tangled nidus of the AVM itself, and enlarged draining venous structures.


AVMs are considered congenital lesions.


Vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF) are thought to be responsible for the development of AVM

CLINICAL FEATURES

  1. Hemorrhage (ICH,SDH,IVH)
  2. Seizure
  3. Headache
  4. Progressive neurologic deficit - May be caused by mass effect or ischemia resulting from local vascular steal phenomenon
  5. If blocks the CSF pathway - Hydrocephalus


Hemorrhage is more likely to be caused by small lesions, while seizures are more likely to be caused by large lesions.

INVESTIGATIONS

  • Imaging
  • CT scan to exclude Intracranial haemorrhages
  • MRI
  • CT angiography better vascular detail than magnetic resonance angiography
  • Cerebral angiography provides definitive diagnosis. It allows grading of the AVM via the following Spetzler and Martin criteria.

TREATMENT

Surgery (craniotomy)
  • Advantages: immediate and permanent recovery after complete resection by craniotomy
  • Disadvantages: Intraoperative bleeding, damage to adjacent neural tissue, and ischemic stroke
  • Benefit of invasive treatment for unruptured AVMs has never been proven


Embolization
  • Occlusion of blood vessels with coils or particles or glue introduced by a radiographically guided catheter
  • An invasive procedure
  • Use it as adjuvant therapy prior to craniotomy to decrease intraoperative bleeding and reduce the size of AVM
  • Is Curative in lesions <1 cm in diameter that are fed by a single artery 


Stereotactic radiosurgery
  • Noninvasive 
  • Can access all anatomic locations of the brain 
  • It can only treat smaller lesions 
  • Takes 2 or more years for a full destructive effect

This is the Xray of the right knee of a 72 year old patient who was complaining  of sudden onset  of severe pain and swelling of the right knee pain associated with severe neck pains, headache, high fever  with symptoms of the central nervous system.The patient's cerebrospinal fluid was almost clear and showed no sign of viral infection.Patient was initially treated  with non steroidal anti-inflammatory drugs with less improvement and then he was given corticosteroids  and he improved his condition dramatically.


Identify this Xray?
What are the other important investigations that you would do in this patient?

Man with Right Hip pain

Thursday, February 25, 2010 15 comments

This is a Xray of a right hip of a 58 years old male patient who was previously diagnosed with ulcerative colitis and was on Prednisilone treatment  now complaining of gradual onset of mild to moderate hip pain which was becomes worse when he was trying to lift some heavy objects from affected side.But his movements of the hip were not restricted in to a greater extent.


Identify this Xray?



ANSWER

AVASCULAR NECROSIS OFTHE HEAD OF THE FEMUR


Also known as osteonecrosis, aseptic necrosis, ischemic bone necrosis
Resulting from the temporary or permanent loss of the blood supply to an area of bone
Some regions of the human skeleton have a much higher tendency to develop ischaemia
  1.  neck of femur
  2.  proximal pole of the scaphoid bone
  3.  body of the talus

CAUSES

Trauma:
  • Fracture of the neck of femur
  • Complication of osteo- and rheumatoid arthritis
  • Neuropathic joint


Idiopathic:
  • Typically middle aged men
  • Affects hips and knees


Perthe's disease


Theimann's disease


High levels of steroids:
  • Iatrogenic
  • Cushing's syndrome
  • Pregnancy


Systemic disease:
  • SLE
  • Sickle cell anaemia
  • Infective endocarditis
  • Chronic liver disease
  • Pancreatitis
  • Alcoholism
  • Hyperlipidaemia
  • Hypertension
  • Caisson disease
  • Gaucher's disease
  • Diabetes mellitus
  • Polycythaemia rubra vera
  • Radiation

CLINICAL FEATURES

Primarily affects the joints at the shoulder, knee, and hip
Avascular necrosis usually affects people between 30 and 50 years of age
Onset may be insidious but often there is a dramatic onset of pain.

INVESTIGATIONS

X-ray the avascular bone appears dense (whiter)
Early stage of the disease x-ray images usually appear normal so Bone scans is useful

TREATMENT

Hip joint Avascular Necrosis is a common indication for total hip replacement in older patients


Hip resurfacing or metal on metal (MOM) resurfacing in younger patients and Realignment osteotomy


Bisphosphonates- reduces the rate of bone breakdown by osteoclasts, thus preventing collapse

This is a plain abdominal Xray of 72-year-old woman who presented with abdominal pain  especially after eating which was associated with nausea and vomiting .And on examination of that woman, doctor revealed that she was icteric and there was a palpable mass on the right upper quadrant of the abdomen.




Identify the Xray?
What is the possible complication of this condition that she may be having in future?




ANSWER

PORCELAIN GALLBLADDER
(calcifying cholecystitis, or cholecystopathia chronica calcarea)


Porcelain gallbladder means the wall of the gallbladder has been calcified to a hard and bluish white texture resembling porcelain ceramic. 


It is predominantly found in overweight female patients of middle age.(male-to-female ratio is 1:5)


Gallstones are present in 90% of patients with porcelain gallbladder


Low-grade chronic inflammation(chronic cholecystitis)t intramural hemorrhage and an imbalance in calcium metabolism are implicated for the condition


Occurrence of gallbladder carcinoma(commonly adeno carcinoma) is remarkably high in patient with porcelain gallbladder and patients with gallbladder carcinoma usually have a poor prognosis

CLINICAL FEATURES

  1. Abdominal pain (especially after eating)
  2. Jaundice
  3. Vomiting
  4. Palpable mass may occasionally be found

INVESTIGATIONS

  • Plain abdominal Xray-galllbladder is seen as having semi radiolucent appearance
  • Non-functioning gallbladder on oral cholecystogram
  • Ultrasound Scan
  • CT Scan

TREATMENT

Prophylactic cholecystectomy to prevent gallbladder carcinoma

INFANT WITH DROOLING OF SALIVA

Monday, February 22, 2010 16 comments

These are the two Xrays (Ap view and Lateral View) of a 02 weeks old infant who was brought to the hospital because of the drooling of Saliva and mother has noticed that during breast feeding the infant begins to cough and struggle as the fluid returns through the nose and mouth.

What are the Abnormalities  you would see in these Xrays?
What are the other important fact that you would like to ask from the mother? 
What are  the tests that you would do to confirm the diagnosis?

Lady with Dyspnoea and Cough

Saturday, February 20, 2010 25 comments

This is a PA chest Xray of a 43 year old  woman who was presented with Shortness of Breath on exertion(Dyspnoea), Cough and Chest pain.Other than the pulmonary symptoms she also complains of milld fever and loss of appetite.

Respiratory Examination was normal other than bilateral crackles.


Comment  on her Chest Xray?
What are the Differntial Diagnosis?

Woman with Eye pain and Poor Vision

Wednesday, February 17, 2010 3 comments

This is a Axial fat-suppressed postcontrast  MRI of a 38 years old woman complaining of  left eye pain and reduction in the vision over three days duration.
Identify this MRI?
What are the common causes for this?

This is abdominal Xray of a 73 years old male who came to the surgery casualty ward complaining of  severe colicky type abdominal pain particularly in the left lower quadrant,gross abdominal distension and not passing stools and flatus for 1 day .This patient  was on long term use of laxatives for chronic constipation.On examination of his abdomen, It was tympanic and palpable mass found in the Abdomen.
What is the Diagnosis?



A 38-year-old woman presented with a sudden and severe headache in the left side of the head  associated with  Loss of consciousness during her job.On examination she was found to have left sided dialated pupil and at the time of examination her GCS was 15/15.An emergency CT was done.
The Left sided carotid artery angiography of her is given here.
Identify what is the abnormality and the anotomical location of that abnormality?
What would be the reason for her Clinical Picture?


 

This is a PA chest Xray of a 63 year old man  who undergone recent renal transplant came to the hospital complaining of mild fever and cough associated with headache for more than 1 month duration.And he has had recent weight loss also.
Comment on this Xray?
What are the other Physical signs you would expect in this patient?

This is a  Xray of the Right foot taken from a 57 years old man who was complaining of abrupt onset of  swelling  and pain of the big toe of  the right foot.He was a known patient with hypertension and was on Hydroclorothiazide.On examination of  the Big toe, it was hot,swollen and tender.
Identify the Xray changes and what is the Diagnosis?


This is a lateral Xray showing part of the Spine of 68 year old  man who came to the Orthopedic Clinic complaining  of  back pain over the lumbo sacral area.In  addition to the lower back pain he was also complaining of generalized body weakness and diffuse type of headache also.During last 6 months of period he has been suffering from recurrent lower respiratory  tract infections and he was  treated for that.
On examination he was  ill loking and pale.No Lower limb muscle wasting,weakness or sensory impairement.

Comment  On this Xray?
What are the differential Dx in this patient?
What are the Investigations you  would like to do in this patient to come to the defenitive Diagnosis?

This is a Xray of the upper limbs taken from 45 year old woman who had marked deformity of the limbs associated with short stature came to the Clinic because of having a local swelling in the ulnar region of the right hand.What is the diagnosis and what is the risk that she may be having in future?

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