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Vol. 23, No. 1, January, 2015
(Published in June 2018)
BANGLADESH JOURNAL OF
RADIOLOGY AND IMAGING
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Prof Abu Saleh Mohiuddin
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Col Zoherul Islam
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Prof Md Mizanur Rahman
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Dr Delwar Hossain
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Dr Syed Maksumul Haque
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Dr Mahmud Uz Jahan
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PresidentProf Md Enayet Karim
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(Sylhet Division)Dr Md Hafizur Rahman
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(Barisal Division)Prof Shibesh Sarker(Rangpur (Division)
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Dr Md Motiur Rahman(Mymensingh Division)
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CONTENTS
Editorial
l DEXA Scan, Modality for Screening Osteoporosis 1Rita Majumder
Original Articles
l Diagnostic Performance of Magnetic Resonance Imaging in Lumbar Disc Herniation 3
Aliza Mamataz, Akand Fazle Rabbi, Md. Khalilur Rahman, Rabindranath Sarkar,
Shahryar Nabi, Shamim Ahmed, Farhana Chowdury, Tahmina Yasmin
l Correlation between Ultrasonography & Mammographic Breast Patterns 8Jafreen Sultana, Abu Saleh Mohiuddin, Md Towhidur Rahman, Naffisa Abedin,
Md Mofazzal Sharif, Sarwar Kamal, Swajal Chandra Das
l Evaluation of Ultrasonography As a Diagnostic Modality for Urinary Bladder 13
Mass with Histopathological Correlation
Partha Pratim Saha, Bibekananda Halder, Shyamal Kumar Roy, Md Sazzad Hossain,
Farida Khatun Chhobi, Md Shahidul Islam, Md Ashikur Rahman Mazumder, Md Maksudul Azim
l Role of Diffusion Weighted MRI in Evaluation of Acute Ischemic Stroke 19
Sharzia Asma-Ul Hosna, Salahuddin Al-Azad, Enayet Karim, Mahbuba shirin,
Bishwajit Bhowmik, Syeeda Showkat, Shaila Jabeen, Kazi Zahrul Haque
l Role of MRI in the Evaluation of Pituitary Adenomas with Histopathological Comparison 25
Snigdha Sarker, Farid Ahmed, Bibekananda Halder, Sukhomoy Kangsha Banik,
Md Rued Hossain, Swati Munshi, Rownak Afrin, Mohammad Sazzad Hossain
l Duplex Colour Doppler Evaluation of Ophthalmic Artery in Diabetic Retinopathy 30
Patients and Normal Subjects
Naffisa Abedin, AS Mohiuddin, Jafreen Sultana, Abdullah Shahriar, Md Anisur Rahman Khan,
Hasina Begum, Mst. Jesmin Ara Parven, Mahmuda Sultana
l Correlation of Mental Status of Elderly Subjects with Cerebral White Matter T2 36
Hyperintensities in MRI
Naffisa Abedin, Niraj Regmi, Abu Saleh Mohiuddin, Abdullah Shahriar,
Muhammad Irfanul Alam, Nayema Rahman, Hashina Bilkish Banu
Review Article
l Unilateral Pulmonary Hypoplasia - A Case Report and Literature Review 42
Shah Muhammad Mustaquim Billah, Jahiruddin Mohammad, Kona Ghosh, Husne Ara,
Farhana Kamal Kumu, Regina Bilquise Tania, Molua Jahan, Rumana Parvin
Case Reports
l Pancreatitis with Unusual Sequelae: A Case Report 46
Mahfuz Ara Ferdousi, Farzana Shegufta, Ishtiaque Mohammad Behnom,
Mousumi Mondal, M Irfanul Alam
l Bilateral Thalamic Hyperdensities - A Diagnostic Feature of Sandhoff’s Disease 49
Syeeda Showkat, Abishek Pokhrel, Bishwajit Bhowmik, Shahryar Nabi,
Shaikh Md Nuruzzaman, Anindita Datta
BANGLADESH JOURNAL OF
RADIOLOGY AND IMAGING
Volume 23 Number 1 January, 2015
BANGLADESH JOURNAL OF RADIOLOGY AND IMAGING 2015; VOL. 23(1): 1
EDITORIAL
DEXA Scan, Modality for Screening Osteoporosis
Bone mineral density test is used to measure the
amount of mineral (mainly calcium) in bone by
using low dose of x-ray. This is also known as dual
energy x-ray absorptiometry or DEXA scan.
This test is performed to –
• Diagnose bone loss and osteoporosis.
• Predict risk of future bone fracture.
• See how well the medicines used for treatment
of osteoporosis is working.
DEXA scan are of two types-
• Central DEXA – To detect bone density of axial
skeleton
• Peripheral DEXA- to detect bone density in
peripheral part of the body, such as wrist,
fingers, leg, heel etc.
The people who should routinely go for this test
are-
• Woman aged 65 years or older.
• Man aged 70 years or older.
• Woman under 65 years of age and man aged50 to 70 years are also at increased risk ofosteoporosis if they-
• Have a broken bone caused by normalactivities.
• Have chronic rheumatoid arthritis, CKDetc.
• Have early menopause.
• Has Taken long time corticosteroidtherapy like every day for more than 3months.
• Have a strong family history of osteoporosis.
The test result is reported as T score and Z
score.
In T score bone density is compared with that of a
healthy young woman. The normal range of T score
is ‘-1’ or above. T-Score between ‘-1’ and ‘-2.5’
means low bone density or osteopenia.
Osteoporosis is the diagnosis when T- Score is
below -2.5. Lower a person’s T score means the
lower the bone density of the person. The
treatment recommendation depends on total
fracture risk.
In Z score the bone density is compared with that
of the people of patient’s age, gender and race.
The absolute value of Z score tells about how many
standard deviations of the patient away from the
mean. If Z score is equal to ‘0’, it is on the mean. If
the score is ‘+1’ or ‘-1’, it is one standard above or
below the mean.
This test is painless as if someone is doing an x-
ray examination only. It bears less risk because a
very low radiation is used. DEXA scan can instantly
show the bone density of a person and thus can
play dramatic role in the reduction of number of
osteoporotic bone fractures. So this test could be
performed for screening purpose to reduce the
sufferings of people caused by bone fracture due
to osteoporosis.
Dr. Rita Majumder
MBBS, M-Phil (Radiology & Imaging).
Radiologist,
Dhaka Medical College & Hospital
BANGLADESH JOURNAL OF RADIOLOGY AND IMAGING 2015; VOL. 23(1): 3-7
ORIGINAL ARTICLES
Abstract
Objective: To evaluate the diagnostic performance
of MRI in lumbar disc herniation, to compare the
MRI diagnosis with per-operative diagnosis and to
find out the validity of MRI for pre-operative
diagnosis of lumbar disc herniation. Methods: This
study was carried out in the Department of
Radiology and Imaging, Dhaka Medical College
Hospital, Dhaka on 99 patients of any age group
who were clinically suspected of having lumbar disc
herniation and referred for MRI of lumbo-sacral
spine during July 2014 to June 2016. The per-
operative diagnosis were compared with MRI
diagnosis and for validity of study outcome,
sensitivity, specificity, positive predictive value,
negative predictive value and accuracy of MRI for
evaluation of lumbar disc herniation were calculated.
Results: In this study, more than half (53.54%)
patients were in 3rd decade with a male female ratio
was 2.41:1. Lumbar disc herniation was mostly found
at L4-L5 level (58.59%), among them 60.61% of study
subject were stressful and 39.39% were sedentary.
The validity of MRI was 94.44% sensitive, 77.78%
specific, and 93% accurate in detecting lumbar
herniated disc. Conclusion: Considering the high
validity parameters it can be concluded that
magnetic resonance imaging is a useful modality
for detection of lumbar disc herniation.
Key Words: Lumbar Disc, Herniation, MRI
Introduction
Herniation is defined as a localized displacementof disc material beyond the limits of the
Diagnostic Performance of Magnetic Resonance
Imaging in Lumbar Disc HerniationALIZA MAMATAZ1, AKAND FAZLE RABBI2, MD KHALILUR RAHMAN2, RABINDRANATH
SARKAR2, SHAHRYAR NABI2, SHAMIM AHMED2, FARHANA CHOWDURY3, TAHMINA YASMIN4
intervertebral disc space. It is most prominent in
the 3rd and 4th decades of life1. A symptomatic
lumbar disc herniation occurs during the life time
of approximately 2% of population. Risk factors
include male gender, age (30-50 years), heavy
lifting or twisting and stressful occupation2.
Lumbar disc herniation is one of the most common
causes of low back pain. Low back pain is one of
the most common patient complaints and can lead
to serious limitation of activity3. It is also a major
public health concern in Bangladesh. A herniated
disc can be sub-classified as protruded, extruded
and sequestered4. Over 90% disc herniation occurs
at the level of L4-L5 or L5-S1. 93% are inside the
spinal canal, 3% are predominately located in the
intervertebral foramen and 4% are extra-
foraminal5. Symptoms typically commence with a
period of back pain followed by sciatica. There may
be paraesthesia, motor weakness, loss of reflexes
and reduction in straight leg raise. A large midline
disc herniation may compress the cauda equina
leading to cauda equina syndrome defined by bowel
and/or bladder difficulties, saddle anaesthesia and
lower limb sensory and motor deficits6. The MRI
has provided clinicians with a non-invasive, safer,
without radiation hazards, more informative and
has very few complications for viewing lumbar
anatomy in great details and various patho-
anatomical changes in lumbar disc herniation. The
contrast sensitivity and the multiplanar imaging
capability of MRI provide a unique advantage7. MRI
exquisitely deliniates herniated nucleus pulposus
and the relationship to adjacent soft tissues5. MRI
has proven to be indispensible tool for orthopedic,
1 Junior Consultant, Department of Radiology & Imaging, Kurmitola General Hospital, Dhaka. 2 Associate
Professors, Department of Radiology and Imaging, Dhaka Medical College Hospital, Dhaka. 3 Radiologist,
Sylhet M.A.G. Osmani Medical College and Hospital, Sylhet. 4 Radiologist, Sir Salimullah Medical College
and Mitford Hospital, Dhaka
spine and neurosurgeon in herniated lumbardiscs8. Previous studies indicate that MRI canidentify lumbar canal stenosis and herniatedlumbar disc. The accuracy of MRI for predictingthe presence of disc herniation at surgery isrelatively high (varying from 76% to 96%).Thus ithas become the choice of investigation for patientssuspected of lumbar disc herniations9.
In Bangladesh only a very few studies have beendone on pre-operative diagnosis of lumbar discherniation by MRI. This study was designed to findout and validate the diagnostic performance of MRIin the diagnosis of lumbar disc herniation.
Methodology:
This cross sectional study was carried out in theDepartment of Radiology and Imaging, Dhaka MedicalCollege Hospital, Dhaka on 99 patients of any agegroup who were clinically suspected of having lumbardisc herniation and referred from the Department ofOrthopedic Surgery and Neurosurgery of DhakaMedical College Hospital, Dhaka during July 2014 toJune 2016 for MRI of lumbar spine. MRI of Lumbo-sacral spine were done in all to evaluate and comparethe MRI diagnosis of lumbar disc herniation with thatof per-operative diagnosis and thus to find out thesensitivity, specificity, positive predictive value,negative predictive value and accuracy of MRI inevaluation of lumbar disc herniation.
Proper written consent was taken from the patientor guardian and was assured of keeping the resultsconfidential. All patients were evaluated by detailhistory and clinical examination with specialemphasis on clinical features. Subsequently MRI oflumbosacral spine was performed in all cases by a0.3 Tesla open MRI machine. T1W and T2W imagewith axial and sagittal scan was taken using slicethickness 05 mm. Patients were followed up duringthe surgery and the MRI and per-operative findingsand diagnosis were collected. Data were collectedin pre-designed structured data collection sheets.
Diagnostic criteria:Protrusion:When some inner fibers of theannulus tear but the outer layers remain intact,the nucleus can focally herniate through the innertear and is called a disc protrusion.
Extrusion: A disc extrusion occurs when thenucleus pulposus herniates through a completetear of the annulus fibrosus and is contained onlyby the posterior longitudinal ligament.
Sequestrated/ free fragment : When an extrudednucleus pulposus breaks free of the parent disc, itis termed a sequestrated disc or free fragment.
Statistical analysis of data: For the validity ofthe study outcome, sensitivity, specificity, accuracy,positive predictive value and negative predictivevalue of MRI in the diagnosis of the lumbar discherniation were calculated after confirmation ofthe diagnosis by operation.
Results
In the study highest incidence of lumbar discherniation was found in the 3rd decade of lifeoccurring in 53 (53.54%) cases followed by 4th
decade occurring in 42 (42.42%) cases and in 5th
decade 04 (04.04%) cases respectively.
Sex incidence of lumbar disc herniation was 70(70.71%) in male and 29 (29.29%) in female. Theincidence of lumbar disc herniation was 60 (60.61%)in stressful and 39 (39.39%) in sedentary workers.
Symptoms showed multiple responses with 99 (100%)patients presented with low back pain, 86(86.87%)presented with pain radiating to lower limb,81(81.82%) presented with restricted SLR,17(17.17%)presented with bowel-bladder involvement,64(64.65%) presented with weak lower limb reflexes,85(85.86%) presented with motor involvement and
77(77.78%) presented with sensory involvement.
Table I
Shows MRI diagnosis (n=99)
MRI diagnosis Frequency Percentage
Lumbar disc 87 87.88
herniation present
Lumbar disc 12 12.12
herniation absent
Total 99 100
Table II
Shows per-operative diagnosis (n=99)
Per-operative Frequency Percentage
diagnosis
Lumbar disc 90 90.91
herniation presentLumbar disc 09 09.09herniation absent
Total 99 100
Bangladesh Journal of Radiology and Imaging Vol. 23(1): January 2015
4
Table-III shows the validity test results. Sensitivity,specificity, positive predictive value, negativepredictive value and accuracy of MRI in the diagnosisof lumbar disc herniation were 94.44%, 77.78%,97.70%, 58.33% and 93.00% respectively. Table IIIalso shows that MRI detected herniated lumbar discwas 87 cases (87.88 %) of which 85 (85.86%) wasproved to have herniated lumbar disc per-operatively.
Discussion
A total of 99 patients who fulfilled the inclusion
and exclusion criteria were included in this study
during July 2014 to June 2016.
In this present study it was observed that 53(53.54
%) cases were in 3rd decade, 42 (42.42%) cases were
in 4th decade and 04(04.04%) cases were in 5th
decade with a mean age of 39.59 ± 5.88 years and a
range of 32 to 58 years. Symptomatic lumbar disc
herniation occurs most commonly in individuals
between the ages 30-50 years10.
In this study it was observed that among the 99
patients, 71% were male and 29% female with a
male female ratio of 2.41: 1(70.68:29.32).
This study showed that 60.61 % of the study
subjects were stressful in occupation and 39.39%
was sedentary. Williams et al also showed that
risk factors included stressful occupation2 and
Table III
Validity of MRI diagnosis compared to per-operative diagnosis
MRI diagnosis Per-operative diagnosis Total
Lumbar disc Lumbar discherniation present herniation absent
Lumbar disc 85 02 87
herniation present (85.86%) (02.02%) (87.88%)
Lumbar disc 05 07 12
herniation absent (05.05%) (07.07%) (12.12%)
Total 90 09 99
(90.91%) (09.09%) (100%)
(TP-true positive, FN-false negative,TN-true negative, FP-false positive)
Fig.-1: Sag T2 and axial T2WI of Protruded
lumbar disc at L5-S1 level with cranial extension
and spinal canal stenosis
Fig.-2: Sag T2 and axial T2WI of Extruded lumbar
disc at L4-L5 level
Fig.-3: Sag T2 and axial T2-WI of sequestered
lumbar disc at L4-L5 level
Diagnostic Performance of Magnetic Resonance Imaging in Lumbar Disc Herniation Aliza Mamataz et al
5
Baldwin showed that sedentary occupation is also
a big factor10. Similar findings were also observed
by Kamal et al12 who showed an incidence of
lumbar disc herniation of 60% in manual workers
and 40% in sedentary workers.
In this study, lumbar disc herniation was mostly
seen at L4-L5 (58.59%) level followed by L5-S1
(35.35%). Roy11 in his study found 68.57% of the
patients had lumbar disc herniation at the L4-5
level, 31.42% of the patients had lumbar disc
herniation at the L5-S1 level. Hossain13 in his
analysis showed that distribution of intervertebral
disc lesions in lumbosacral region is common in
the L5-S1 (95%) and L4-L5 (92%).
In the current study 100% patients presented with
low back pain and 86.87 % presented with pain
radiating to lower limb. Natural history of disc
disease is one of recurrent episodes of low back
pain & leg pain6.
Out of 99 cases, 87(87.88%) were diagnosed as
lumbar disc herniation by MRI and among them
85(85.86%) were proved to be lumbar disc
herniation during operation. Modic14 showed, at
the operative levels, there was 82.6% agreement
between MRI and surgical finding for both type
and location of disease.
In this study, MRI had 94.44% sensitivity, 77.78%
specificity, 93% accuracy, 97.70% positive
predictive values and 58.33% negative predictive
values. In the study of Foristall15 accuracy of MRI
was 90.3% and sensitivity was 91.7%. Weiner &
Patel8 showed that, MRI was found to be 72%
sensitive, 68% specific and 70% accurate in
detecting containment status of lumbar herniated
discs.
Conclusion
Considering the high validity parameters it can be
concluded that magnetic resonance imaging is a
useful modality for detection of lumbar disc
herniation.
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Intervertebral Disc by minimally invasiveopen Lumbar discectomy. MS (ORTHO)Thesis, Bangabandhu Sheikh Mujib MedicalUniversity.2005.
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Myelography. American Journal Of
Radiology. 1986 oct; 147(4):757-65.
15. Forristal RM, Marsh HO, Pay NT. Magnetic
Resonance Imaging and contrast CT of lumbar
spine: Comparison of diagnostic methods
correlation with surgical findings. Spine.
1988.13(9):1049-54.
Diagnostic Performance of Magnetic Resonance Imaging in Lumbar Disc Herniation Aliza Mamataz et al
7
Correlation between Ultrasonography &
Mammographic Breast PatternsJAFREEN SULTANA1, ABU SALEH MOHIUDDIN2, MD TOWHIDUR RAHMAN3, NAFFISA
ABEDIN4, MD MOFAZZAL SHARIF5, SARWAR KAMAL6, SWAJAL CHANDRA DAS7
1. Associate Professor, Department of Radiology & Imaging, BIRDEM. 2. Professor, Department of Radiology &Imaging, BIRDEM. 3. Assistant professor, Department of Radiology & Imaging, BIRDEM. 4. Assistant Professor,
Department of Radiology & Imaging, BIRDEM. 5. Ex MD student, BIRDEM 6. Radiologist, Kurmitola General
Hospital, Dhaka. 7. Assistant Professor, Department of Radiology & Imaging, Sylhet M.A.G. Osmani Medical
College, Sylhet.
Abstract:Objective: To find out the correlation betweenultrasonographically assessed adult female breast
parenchymal patterns & mammographic breastparenchymal patterns. Method: This crosssectional study was done on 50 subjects aged 24-40
years in the department of Radiology and Imaging,BIRDEM from 1st June, 2014 to 30th May 2015 whoattended the department for screening
mammogram. After reviewing clinical history,special emphasis was given on menstrual history,obstetric history, family history and history of drug
intake. Clinical examination of both breasts wasperformed. Then they underwent mammography.Cranio-caudal & medio-lateral oblique projections
were taken for each mammary gland. All themammographic films were interpreted by an expertradiologist of the department. The subjects with
negative mammographic findings underwentultrasonographic examination of both breasts bythe researchers first for typing of breast
parenchyma and the findings were confirmed byanother radiologist of department who did notknow mammographic typing of the same subjects
and classified according to the Novak & Bollmancriteria. Result: In this study, among 50 womenall the mammograms & sonographic breast
parenchymal patterns were divided into four grades& to find out association among them. The resultsof the interpreter analysis were Kappa = 0.94 with
p < 0.001. This measure of agreement, whilestatistically significant, is almost perfect agreement.Conclusion: In this study, a significant correlation
was found between ultrasonographically assessedfemale breast parenchymal patterns andmammographic breast parenchymal patterns.
Key words : Ultrasonography, Mammography.
Novak & Bollman criteria.
Introduction:
The breast is a modified sweat gland that is
composed of 15 to 20 lobes. They are accessory
organs of the female reproductive system. Each
lies on the anterior chest wall and anterior to the
pectoralis major muscle between the 2nd and 6th
ribs1.
Sonography of breast is a good imaging modality
for diagnosis of breast diseases.
There are three roles for sonography in breast
imaging: 1. Primary screening 2. Secondary
Screening (following mammography) and
3.Diagnosis
Sonography detected approximately threecarcinomas that were missed by primary screeningmammography per 1000 patients .The lesion weremissed on mammography because they did notcontain calcifications and were obscured bysurrounding or superimposed dense tissue on themammogram2,3.
The sensitivity of mammography in this respect isvariable and influenced by many factors such asage, breast density and family history. One of theimportant factors is the effect of breastparenchymal density4. Three per thousandpatients is the mammographic detection rateexpected for interval cancers in previouslyscreened mammography patients and suggests thatsonography might be very useful as a secondary
screening role in patients who have dense breasts
on mammography. The maximum diameters and
prognoses of lesions detected only by ultra sound
are similar to lesion found by mammographic
screening3,4.
BANGLADESH JOURNAL OF RADIOLOGY AND IMAGING 2015; VOL. 23(1): 8-12
Ultrasonographic parenchymal patterns of thebreast can predict the tissue patterns definedmammographically5. The ultrasound images werealso assessed for both focal abnormalities andgeneral parenchymal patterns of the breast tissue.Parenchymal patterns either by ultrasound or bymammography showed similar associations withage, menopausal status and parity6,7.
The relationship between risk of disease and theparenchymal pattern of the breast have been limitedby the need for mammographic examination. It hastherefore been possible to obtain information aboutthe parenchymal pattern only in women who werereferred for mammographic examination8,9,10.Information about the distribution of parenchymalpatterns in women who are either asymptomaticor not old enough to be admitted to screeningprogrammes is therefore not available. To obtainsuch data, a risk-free method of breast examinationis required that can be applied to randomly selectedmembers of the population. Ultrasound of the breastmay be suitable for this application11. Real-timeultra-sound imaging if capable of defining similarbreast parenchymal pattern, would add a necessarydimension of portability that would facilitate thecomparison of ultrasonographic breast tissuepatterns in populations at different risks12,13.
The proven and approved role for breast ultrasoundis usually performed in a targeted fashion followingmammography and clinical examination alone toprovide a more specific diagnosis14. Specific goals
of targeted diagnostic sonography to categorizationof breast diseases such as BIRADS, to preventbiopsy and short interval follow up mammographyof benign lesions, to guide interventions of all types,to give feedback that improves clinical andmammographic skills and to find malignancies thatare missed by mammography9.
Novak & Bollman10 1983 classified the sonographicparenchymal patterns into four major groups-
P1: Fatty hypoechogenic breast with lobules in thinfibrous septa.
P2: Fatty breast with some dense echoes probablyrepresenting thickened periductal connectivetissue.
P3: Some coalescence of the dense echoes withdecreased lobular fat.
P4: Complete coalescence of the fibrous stromaresulting in a dense echogenic breast.
In 1967 Wolfe developed a classification ofmammographic patterns by dividing breasts intofour categories. This has been adapted by theAmerican College of Radiology (ACR) in the ACRBreast Imaging Reporting and Data System(BIRADS)15,16 as grade 1 through 4 as.
N1 Which is fatty breast (Lucent) Grade 1
P1 15-25% density in mammogram Grade 2
P2 15-25% density in mammogram Grade 3
DY Extremely dense Grade 4
Fig.-1 : Mammogram and Ultrasonogram of 45 years with P2 mammary parenchyma.
Correlation between Ultrasonography & Mammographic Breast Patterns Jafreen Sultana et al
9
Material and methods:
This cross sectional study was carried out in the
department of Radiology and Imaging, BIRDEM.
This study was done on 50 subjects aged 24-40
years in the department of Radiology and Imaging,
BIRDEM from 1st June 2014 to 30th May 2015.
The mammograms were performed on α – RT
mammography unit composed of – Rhodium and
Molybdenum targets, having two focal spots (0.3
mm and 0.1 mm for magnification purpose),
Secondary radiation grid, Breast positioning
capability and Automatic exposure control (AEC).
Film and even compression was applied by using
foot control to improve resolution, reduce the dose
and scatter radiation. After thorough clinical
examination two views for each breast, cranio-
caudal and medio-lateral oblique mammograms
were taken. The equipment used for
ultrasonography was Siemens Sonoline Anteres
and Medisone Sonoace 800 live machines with
multi-frequency linear transducer of 6-10 MHz.
Patient’s position during ultrasonography was as
below –a) Patient was in supine position with her
arm raised above her head. b) A pillow was placed
along the supine patient’s side so the breast does
not fall into axial. c) Patient can be rolled into a
contra lateral posterior oblique position to a degree
to better image the lateral aspect of breast. d)
Breast was scanned in the radial plane from outer
margin of the breast to the nipple, clockwise. Both
longitudinal & transverse plane was used.
Correlation of sonographic parenchymal patterns
of the breast with mammographic patterns was
calculated by Kappa test. A more complete list of
how Kappa might be interpreted is given in the
following table-
Kappa Interpretation
<0 Poor agreement
0.0 – 0.20 Slight agreement
0.21 – 0.40 Fair agreement
0.41 – 0.60 Moderate agreement
0.61 – 0.80 Substantial agreement
0.81 – 1.00 Almost perfect agreement
Results:
A total of 50 cases were included in this study andthey were divided into three age groups. The ageranged from 24 to 40 years and the maximumnumber was found in the age group of 24-30 years.
In study subjects, the mammographic pattern werefound to have 10 (16.7%) fatty breast (Lucent), 12(25.0%) predominantly fatty with 15-25% density,16 (33.3%) heterogeneously dense occupying upto75% density and 12 (25.0%) extremely dense.
Fig.-2 : Bar diagram showing the mammographic
pattern of study subjects.
In this study subjects the sonographic pattern were
found 12 (20.8%) P1, 12 (25.0%) P2, 16 (33.3%) P3
and 10 (20.8%) P4.
Fig.-3 : Bar diagram showing the sonographic
pattern of the study subjects.
Fatty breast (Lucent) was in 10 women out of which100 % showed P1. Predominantly fatty with 15-25% density was in 12 women and 100% showedP2. Heterogeneously dense occupying upto 75%density was 16 women out of which 93.8% showedP3 and 6.2% showed P4. Extremely dense was in12 women and 100 % showed P4. The results weredepicted in table below-
Bangladesh Journal of Radiology and Imaging Vol. 23(1): January 2015
10
Breast parenchymal pattern was evaluated by
mammography and sonography. The results of the
interpreter analysis are Kappa = 0.94 with p value
<0.001. This measure of agreement, while
statistically significant, is almost perfect
agreement.
Discussion:
In this study 50 patients were divided into three
age groups. The mean age of the subjects were
32.8±4.5 years ranged from 24 to 40 years.
The mammographic pattern were found 10(16.7%)
in fatty breast (Lucent), 12(25%) predominantly
fatty with 15-25% density, 16(33.3%) hetero-
geneously dense occupying upto 75% density and
12(25%) extremely dense.
The highest P2 & DY breast parenchymal pattern
were 52.8% & 36.8% in the age group of 24-30 years,
26.7% & 20% in the age group of 31-35 years and
14.3% & 14.3% in the age group of 36-40 years. So
they are considered as high risk radiological index.
The breast density in the age group of 26-30 years
were DY=50%, P2=16.7%, P1=20%, N1=62.5% and
in the age group of 31-35 years were DY=30.0%,
P2=33.3%, P1=40%, N1=25% and in the age group
36-40 years were DY=20%, P2=50%, P1=40%,
N1=12.5%.
Breast parenchymal pattern was evaluated by
mammography and sonography. Fatty breast
(Lucent) was in 10 women out of which 100%
showed P1. Predominantly fatty with 15-25%
density was in 12 women and 100% showed P2.
Heterogeneously dense occupying upto 75% density
was 16 women out of which 93.8% showed P3 and
6.2% showed P4. Extremely dense was in 12 womenand 100% showed P4.
The analysis showed Kappa=0.94 with p<0.001,which indicates that the measure of agreement,was almost perfect agreement.
Conclusion:
Significant correlation was found betweenultrasonographically assessed female breastparenchymal patterns and mammographic breastparenchymal patterns. So during ultrasonographyradiologist may give emphasis on breastparenchymal pattern. So that high risk group canbe isolated for regular follow up. Moreover,Ultrasonography is available in almost every cornerof our country & of less costly and free fromradiation hazards.
References:
1. Boyd NF, O’ Sullivan B, Campbell JE, FishellE, Simor I and Cooke G. Mammographic signsas risk factors for breast cancer. British
Journal of Cancer 1982a; 45: 185-93.
2. Boyd NF, O’ Sullivan B, Campbell JE, FishellE, Simor I, and Cooke G. Bias and theassociation of parenchymal patterns withbreast cancer. British Journal of Cancer
1982b; 45: 179-84.
3. Olsen O and Gotzsche PC. Cochrane reviewon screening for breast cancer with
mammography. Lancet 2001; 358: 1340-2.
Table-IV
Correlation of sonographic breast pattern with mammographic pattern.
Mammographic Sonographic findings
findings P1 P2 P3 P4
n % n % n % n %
N1 10 100 0 0 0 0 0 0
P1 0 0 12 100 0 0 0 0
P2 0 0 0 0 15 93.8 1 6.2
DY 0 0 0 0 0 0 12 100
Total 10 20.8 12 25 15 31.3 13 27.1
Kappa = 0.94, p value= 0.001
Correlation between Ultrasonography & Mammographic Breast Patterns Jafreen Sultana et al
11
4. Boyd NF, O’ Sullivan B, Fishell E, Campbell
JE and Fishell E. Mammographic patterns
and breast cancer risk: methodological
standards and contradictory results. Journal
of the National Cancer Institute 1984; 72:
1253-59.
5. Laurence H. Bennister & Mary Dyson. Gray’s
anatomy 39th edition. 1859-61.
6. Boyd NF, Wolfson C, Moskowitz M, Carlile T
and Petit M. Observer variation in the
classification of mammographic parenchymal
patterns. Journal of chronic Diseases 1986;
39: 465-72.
7. Buchanan JB, Weisberg RT, Sandoz JP and
Gray LA. Selected prognostic variables for
mammographic parenchymal patterns.
Cancer 1981; 47: 2135-37.
8. Feinstein AR and Kramer MS. A Primer on
quantitative indexes of association. Clinical
pharmacology and Therapeutics 1980; 28: 130-45.
9. Foster FS, Fishell EK, Khodai M and
Harasiewicz K. Initial clinical performance of
a prototype breast imaging system using a
conical/annular array hybrid transducer.
Ultrasonic Examination of the breast 1985;
52: 185-92.
10. Kendall MG. Correlation Methods (John
Wiley and Sons Ltd, London). American
journal of Epidemiology 1965; 32: 101-5.
11. Gravelle IH, Bulstrode JC, Wang DY and
Hayward. The relation between radiographic
features and determinants of risk of breast
cancer. British Journal of Radiology 1980; 53:
107-13.
12. Krook P, Carlile T, Bush W and Hall MM.
Mammographic parenchymal patterns as a
risk indicator for prevalent and incident
cancers. Cancer 1978; 41: 1093-97.
13. Morrison A, Brisson J and Burnstein N.
Relationship between mammographic image
and histology in women who have benign
breast biopsy. American Journal of
Epidemiology 1985; 122: 516-20.
14. Novak D & Bollman R. Standardized real-time
ultrasonic mammography. Ultrasonic
Examination of the Breast 1983; 45: 135-8.
15. Wellings SR & Wolfe JH. Correlative studies
of the histologic and radiographic appearance
of the breast parenchyma. Radiology 1978;
129: 299-306.
16. Whitehead J, Carlile T, Kopecky KJ,
Thompson DJ, Culbert FI & Present AJ et
al. The relationship between Wolfe’s
classification of mammograms, accepted
breast cancer risk factors and incidence of
breast cancer. American Journal of
Epidemiology 1985; 122: 994-1006.
Bangladesh Journal of Radiology and Imaging Vol. 23(1): January 2015
12
Evaluation of Ultrasonography as a Diagnostic
Modality for Urinary Bladder Mass with
Histopathological CorrelationPARTHA PRATIM SAHA1, BIBEKANANDA HALDER2, SHYAMAL KUMAR ROY3, MD SAZZAD
HOSSAIN4, FARIDA KHATUN CHHOBI5, MD SHAHIDUL ISLAM6 MD ASHIKUR RAHMAN
MAZUMDER7, MD MAKSUDUL AZIM8
1. Radiologist, Department of Radiology & Imaging, Sir Salimullah Medical College, Dhaka, 2. AssociateProfessor, Department of Radiology & Imaging, Sir Salimullah Medical College, Dhaka, 3. AssistantProfessor, Department of Radiology & Imaging, Sir Salimullah Medical College, Dhaka. 4. AssistantProfessor, Department of Radiology & Imaging, Sir Salimullah Medical College, Dhaka, 5. AssistantProfessor, Dept. of Physical Medicine, Sir Salimullah Medical College, Dhaka. 6. Associate Professor,Department of Radiology & Imaging, Shaheed Suhrawardy Medical College, Dhaka. 7. Associate Professor,Department of Radiology & Imaging, Sylhet M.A.G. Osmani Medical College, Sylhet. 8. Assistant Professor,Department of Radiology & Imaging, Sylhet M.A.G. Osmani Medical College, Sylhet.
Abstract
Background: Bladder cancer is the most common
tumor of the urinary system. Incidence of bladder
cancer in Bangladesh is not known. Objectives:
To calculate the sensitivity, specificity, positive
predictive value, negative predictive value and
accuracy of gray scale ultrasonography in the
evaluation of urinary bladder mass. Methodology:
This cross-sectional study enrolled 47 patients of
29 to 76 years of age range during the period of
January 2013 to December 2014 and the study was
carried out in the department of Radiology and
Imaging of Sir Salimullah Medical College and
Mitford Hospital, Dhaka. Ultrasonogram (USG)
diagnosis was finally compared with
histopathological diagnosis which was considered
as gold standard. Results: Among 47 patients
included in this study the age ranged between 29-
76 years. Majority of the respondents (42.55%) were
found between 41-60 years of age. Among them
65.95% were male and rest were female. The most
common symptom associated with bladder mass
was haematuria (93.61%), followed by anemia,
suprapubic pain, urgency, burning micturition,
increased frequency, anorexia, pelvic pain, pain in
flank, abdominal pain and abdominal mass. Most
of the malignant lesions involved mostly base
(79.48%) and lateral wall (46.15%) with irregularly
(79.48%) walled isoechoic lesion (51.28%) with
extension into perivesical tissue. Benign lesions
showed involvement of lateral wall of urinary
bladder (87.5%). These lesions revealed as
irregularly margined (87.5%) mass lesion affecting
base (62.5%) & lateral wall (87.5%).
Histopathologically, 21 cases (44.68%) were
diagnosed as Transitional Cell carcinoma and 13
(27.67%) cases as Squamous cell carcinoma. 5
cases (10.63%) were Adenocarcinoma. Cystitis and
adherent blood clot to wall were found as 4 (8.51%)
cases each. Among 47 cases, 39 cases (82.79%) were
diagnosed as malignant and rest 8 (17.21%) cases
were benign, found in histopathology. In USG, 38
(80.85%) were malignant and rest 9 (19.15%) were
benign. Considering histopathological diagnosis
as gold standard test accuracy, sensitivity,
specificity, PPV, NPV and accuracy of USG in
diagnosis of malignant bladder mass were
97.44%,97.43%, 87.5%, 97.43% and 87.5%
respectively. Conclusion: Ultrasonography is a
non invasive available, radiation free procedure
which is used as a first line preliminary diagnostic
procedure. The gray scale ultrasonography is a
useful diagnostic tool for diagnosis of urinary
bladder mass.
Keywords: Ultrasonography, Bladder Mass
BANGLADESH JOURNAL OF RADIOLOGY AND IMAGING 2015; VOL. 23(1): 13-18
Introduction
Bladder cancer is the most common tumor of the
urinary system. Though the incidence of bladder
cancer in Bangladesh is not known, it was
estimated that 68,810 new cases were diagnosed
and 14,100 deaths were caused by bladder cancer
in the United States in 2008. The lifetime risk for
men is 3.4% and for women, 1.2%. Although
bladder cancer can be detected at any age, more
than 70% of new cases are diagnosed in patients
who are 65 years of age or older.1,2 In addition, up
to 70% of patients treated for bladder cancer will
experience a recurrence after treatment. Bladder
cancer rates are nearly four times higher in men
than in women.3,4,5,6, Transitional cell carcinoma
(TCC) accounts for approximately 90% of all bladder
tumors. The second most common cell type is
squamous cell cancer (8%), followed by
adenocarcinoma. Other rarer sub types such as
small cell carcinoma account for less than 1% of
the cases.3,4 Patient symptoms are all nonspecific.
The most common presenting symptom is gross
hematuria, although microscopic hematuria may
be detected at urinalysis. Patients may alsoexperience voiding symptoms such as increasefrequency, dysuria, and pelvic pain and pressure4.
Tumors arising from the epithelial lining of theurinary tract—that is, the renal collecting system,renal pelvis, ureter, bladder, and urethra—arecalled urothelial tumors. The most common type,
accounting for roughly 95% of all malignant
urothelial tumors, is TCC. Bladder cancers and
those in the proximal urethra are commonly
considered lower urinary tract urothelial tumors
to distinguish them from ureteral, renal pelvic,
and calyceal urothelial tumors, which are
collectively referred to as upper urinary tract
tumors.3
The goal of cancer screening is to detect cancer at
an early stage when it is treatable and curable.
The major factors influencing prognosis and
treatment of bladder tumor are histological cell
type, grade of malignancy, tumor size, growth
pattern, depth of bladder wall infiltration and the
presence of metastases in lymph nodes and blood
borne sites. Depth of infiltration refers to the
spread of tumour through the layers of the bladder
wall and has a major impact on treatment choice.7
Cystoscopy is the conventional procedure for
monitoring the bladder and taking biopsy from the
lesion.8 Cystoscopic evaluation and biopsy reveals
the growth pattern, histological cell type and grade
of malignancy.7 Reliable, noninvasive, image-based
method has been needed to be established for
detection of bladder cancer.5 USG has proved to
be an accurate imaging modality for various
cancers.9
Patients with suspected bladder abnormalities were
examined by noninvasive suprapubic sonography
to define the accuracy of ultrasound for detecting
and staging bladder carcinomas by et al.10 In 103
patients, 65 tumors were found by cystoscopy, of
which sonography detected 61 (94%). Four lesions
less than 2–3 mm were missed at the bladder dome,
the ventral wall, and side wall. The sonographic
staging was correct in 83% of all tumor stages with
the lowest value of 69% for T2/T3a tumors;
excluding recurrent tumors, the overall accuracy
increased. From these results, suprapubic
sonography was considered to be a reliable
noninvasive technique for detecting bladder tumors
and for preoperative local staging. The staging
results were comparable with reports in the
literature on the accuracy of intravesical
sonography.
Conventional and contrast-enhanced sonographies
were performed on 34 consecutively registered
patients with bladder tumors by Caruso et al.11 At
gray-scale sonography, interruption of the
hyperechoic bladder wall was considered the main
diagnostic criterion for differentiating superficialand infiltrating tumors. At contrast-enhancedsonography, a tumor was considered superficialwhen the hypoenhancing muscle layer of thebladder wall was intact; disruption of the musclelayer by enhancing tumor tissue was considered
diagnostic of infiltration. A level of confidence in
the diagnosis of tumor infiltration of the muscle
layer was assigned on a 5-degree scale. Receiver
operating characteristic analysis was used to assess
overall confidence in the diagnosis of muscle
infiltration by tumor at both conventional and
contrast-enhanced sonography. Histologic
diagnosis was obtained for all patients. Final
Bangladesh Journal of Radiology and Imaging Vol. 23(1): January 2015
14
pathologic staging revealed 25 superficial tumors
(Ta–T1 disease) and nine muscle-infiltrating
tumors (> T1). Conventional sonography depicted
five of nine muscle-infiltrating tumors, and
contrast-enhanced sonography depicted all nine.
The diagnostic performance of contrast-enhanced
sonography approached that of the reference
standard as well as the diagnostic performance of
gray-scale ultrasound.
Although, CT scan, MRI12, PET-CT scan are better
modalities than USG in detecting and staging
bladder mass with more diagnostic accuracy than
USG. But these modalities are invasive, use
contrast media of radio-pharmaceuticals and have
potential radiation hazards. On the contrary, USG
is a non-invasive, readily available, relatively cheap
method. If care is given during sonography, a
radiologist can accurately detect bladder mass
which would be comparable with other imaging
methods. Sir Salimullah Medical College and
Mitford Hospital is one of the busiest hospital
situated in the capital city, Dhaka. This hospital
provides both the Department of Urology and the
Department of Radiology and Imaging well-
equipped with modern technology. In this hospital
USGs are performed under the direct supervision
of highly specialized and experienced radiologists
with minimum cost. This is the reason for which
the investigator selected the Department of
Radiology and Imaging of SSMC as an ideal place
of study.
Methods:
This cross-sectional study was carried out in the
department of Radiology and Imaging of Sir
Salimullah Medical College And Mitford Hospital,
Dhaka enrolling 47 patients who were referred to
Radiology and Imaging department by Urology
department of Sir Salimullah Medical College and
Mitford Hospital, Dhaka as a clinically suspected
urinary bladder mass for USG of abdomen, during
the period of January 2013 to December 2014.
Prior to the commencement of this study, the
research protocol was approved by the Institutional
Review Board of SSMC, Dhaka. It was assured that
all information and records would be kept
confidential and the procedure would be helpful
for both the surgeons and the patients in making
rational approach of the case management. All
USG examinations were performed with Logiq P5
GE (General Electronics). The diagnostic value of
USG in the diagnosis of urinary bladder mass was
determined by calculating sensitivity, specificity,
accuracy, positive and negative predictive values.
Results
Among 47 patients included in this study the age
ranged between 29-76 years. Mean age was 55.84
± 13.67 (mean ± SD) years. Majority of the
respondents (42.55%) were found between 41-60
years of age. Five (10.63%) subjects were found
below 40 years of age. There were 31 men (65.95%)
and 16 women (34.05%).
Table I
Distribution of Site of involvement of the urinary
bladder masses (n=47)
Type of lesion USG Neoplastic Non-
finding Showing n=39 Neoplastic
involvement area n=08
Base of urinary bladder 79.48 62.50
Lateral wall of urinary 46.15 87.50
bladder
Both base & lateral wall 24.30 15.24
* Multiple responses were elicited and results were expressedin percentage.
Table II
Distribution of echogenicity of lesion of the
urinary bladder masses (n=47)
Type of lesion USG Neoplastic Non-
finding showing n=39 Neoplastic
echogenicity of lesion n=08
Isoechoic 51.28 00
Hypoechoic 32.30 50
Hyperechoic 13.89 50
Mixed echogenic 02.53 00
At histology, 21 cases (44.68%) were diagnosed as
Transitional Cell carcinoma and 13 (27.67%) cases
as Squamous cell carcinoma. 5(10.63%) cases were
Adenocarcinoma, Cystitis and adherent blood clot
to wall were found as 4 (8.51%) cases each.
Evaluation of Ultrasonography as a Diagnostic Modality for Urinary Bladder Mass Partha Pratim Saha et al
15
Table III
Histopathological diagnosis of urinary bladder
mass (n=47)
Findings No. of Percentage
patients
Transitional Cell carcinoma 21 44.68
Squamous Cell carcinoma 13 27.67
Adenocarcinoma 05 10.63
Cystitis 04 08.51
Adherent blood clot to wall 04 08.51
Total 47 100
Among 47 cases, 39 cases (82.79%) were diagnosed
as malignant and rest 8 (17.21%) cases were
malignant found in histopathology. In USG, 38
(80.85%) were malignant and rest 9 (19.15%) were
benign. Out of the 47 study subjects, 39 were
histopathologically confirmed as malignant mass.
Among the confirmed 39 subjects, 38 (True
positive) were diagnosed as malignant mass in
USG accurately, while in 01 (False negative)
subjects, USG failed to clearly diagnose malignant
mass. One subject was false positively considered
as bladder carcinoma. 07 (True negative) subjects
had other than bladder carcinoma as diagnosed by
both USG and Histopathological diagnosis.
Table V
Comparison between Trans-abdominal
sonography with Histopathology, which was
taken as gold standard for evaluation of bladder
mass
USG Histopathological diagnosis Total
Diagnosis (+) ve for (-) ve for
malignancy malignancy
(+) ve for 38 01 39
malignancy (TP) (FP)
(-)ve for 01 07 08
malignancy (FN) (TN)
Total 39 08 47
(TP+FN) (FP+TN) (TP+FP+
TN+FN)
TP + Tru e positive, FP = False Positive, FN = False
Negative, TN = True negative
Considering histopathological diagnosis as gold
standard test sensitivity, specificity, PPV, NPV and
accuracy of USG in diagnosis of malignant bladder
mass were 97.43%, 87.5%, 97.43%, 87.5% and
97.44% respectively.
Table VI
Sensitivity, Specificity, Positive predictive value,
Negative predictive value and Accuracy of USG for
diagnosis of malignant bladder mass considering
Histopathology as gold standard test
Diagnostic parameter Value (%)
Accuracy 97.44
Sensitivity 97.43
Specificity 87.50
Positive predictive value 97.43
Negative predictive value 87.50
Discussion
Bladder cancer which is the most common
malignancy of the urinary tract can be found in
any age, more than 70% of new cases are diagnosed
in patients who are 65 years of age or older. Up to
70% of patients treated for bladder cancer would
experience a recurrence after treatment.
This cross-sectional study was conducted to
evaluate the diagnostic accuracy of Gray Scale
Ultrasonography in the diagnosis of urinary
bladder mass enrolling 47 patients of 29 to 76 years
of age range during the period of January 2013 to
December 2014 in the department of Radiology and
Imaging of Sir Salimullah Medical College and
Mitford Hospital, Dhaka.
Among 47 patients included in this study the age
ranged between 29-76 years. Mean age was 55.84
± 13.67 (mean ± SD) years. Majority of the
respondents (42.55%) were found between 41-60
years of age. There were 31 men (65.95%) and 16
women (34.05%). In a previous study, Crawford et
al. reported that the incidence of urinary bladder
tumors accounting for 5.5% of all the cancer cases
in men. In women, it is accounting for 2.3% of all
cancers .The male to female ratio is 3.8:1 and has
peak incidence at the age of 65.
Bangladesh Journal of Radiology and Imaging Vol. 23(1): January 2015
16
Current study showed that most common symptom
associated with bladder mass was haematuria
(93.61%). 41 subjects (87.23%) had anemia, 38
subjects (80.85%) had suprapubic pain, 53.19% had
urgency, 38.29% had burning micturition, 34.04%
had increased frequency, 27.65% had anorexia,
12.76% had pelvic pain, 10.63% had pain in flank,
6.36% had abdominal pain and 4.25% subjects
presented with abdominal mass. Wong-You–
Cheong et al.4 observed that the most frequent
presentations of bladder mass lesion were
haematuria, Urinary tract infections, irritative
symptoms such as urinary frequency, dysuria, and
urgency.
Most of the malignant lesions involved mostly base
(79.48%) and lateral wall (46.15%) with irregularly
(79.48%) walled isoechoic lesion (51.28%) with
extension into perivesical tissue. Benign lesions
showed involvement of lateral wall of urinary
bladder (87.5%). These lesions revealed as
irregularly margined (87.5%) mass lesion affecting
base (62.5%) & lateral wall (87.5%). These were
the common findings of bladder masses found in
previous studies.4
In present study it was seen that at histology, 21
cases (44.68%) were diagnosed as Transitional Cell
carcinoma and 13 (27.67%) cases as Squamous cell
carcinoma. 5(10.63%) cases were Adenocarcinoma,
Cystitis and adherent blood clot to wall were found
as four (8.51%) cases each. Among 47 cases, 39
cases (82.79%) were diagnosed as malignant and
rest 8 (17.21%) cases were malignant found in
histopathology. In USG, 38 (80.85%) were
malignant and rest 9 (19.15%) were benign.
Vikram, Sandler and Ng3; Wong-You–Cheong et
al4 observed that TCC accounts for approximately90% of all bladder tumors. The second mostcommon cell type is squamous cell cancer (8%),followed by adenocarcinoma. Other rarer subtypessuch as small cell carcinoma account for less than1% of the cases. Tubin et a)13, also described thatSCC is the second most common malignant tumour
of urinary bladder. SCC appears as solid
predominantly hypo echoic, flat infiltrative lesion.
Often associated stone is seen. Sometimes it
appears as poorly defined, irregular solid mass.
Berlac et al,14 reported that Adenocarcinoma of
urinary bladder is rare tumour and often related
with history of chronic cystitis. It is hypo to hyper
echoic mass with presence of calcification. They
are homogeneous to heterogeneous mass with
poorly defined margin. Sometimes it shows central
necrosis. Adherent blood clots are common benign
urinary bladder mass in a patient with haematuria.
They are ill-defined hyper echoic mass commonly
found in base and lateral wall. Repeated sonography
shows decreased in size or dislodgement of the
mass from primary site.13. Cystitis appeared as
focal thickening to polypoid hypo echoic mass lesion
arising from lateral wall and base of urinary
bladder. Mucosal edema and irregularity are
associated features. They are usually associated
with contraction of bladder.15
In current study, Considering histopathological
diagnosis as gold standard test accuracy ,
sensitivity, specificity, PPV, NPV and accuracy of
USG in diagnosis of malignant bladder mass were
97.44%, 97.43%, 87.5%, 97.43% and 87.5%
respectively. Stamatiou et al.16 prospectively
evaluated 173 patients presenting to the outpatient
department with painless hematuria by
transabdominal ultrasound and cystoscopy. For
ultrasonography, the sensitivity (92%), specificity
(98.1%), positive predictive value (94.4%) and
negative predictive value (95.4%) were seen.
Conclusion
Ultrasonography is a non-invasive, easily available,
radiation free procedure. In present study it was
observed that accuracy, sensitivity, specificity, PPV,
NPV and accuracy of USG in diagnosis of malignant
bladder mass were high. So it was concluded that
gray scale ultrasonography is a useful diagnostic
tool for diagnosis of urinary bladder mass.
References
1. Kirkali Z, Chan T, Manoharan M, et al.
Bladder cancer: epidemiology, staging and
grading, and diagnosis, Urology 2005; 66(1):
4-34.
2. Lynch CF & Cohen MB. Urinary system,
Cancer, 1995; 75: 316.
3. Vikram R, Sandler CM & Ng CS. Imaging and
Staging of Transitional Cell Carcinoma: Part
Evaluation of Ultrasonography as a Diagnostic Modality for Urinary Bladder Mass Partha Pratim Saha et al
17
1, Lower Urinary Tract’. AJR; 2009; 192:
1481–1487.
4. Wong-You-Cheong JJ, Wagner BJ, Davis CJ.
From the archives of the AFIP. Transitional
cell carcinoma of the urinary tract: Radiologic-
pathologic correlation. Radio Graphics, 1998;
18: 123-42.
5. Sadow CA, Silverman SG, O’Leary MP,
Signorovitch JE. Bladder Cancer Detection
with CT Urography in an Academic Medical
Center’. Radiology; 2008; 249: 195-2002.
6. Jacobs BL, Lee CT, Montie JE. Bladder cancer
in 2010; How far have we come?’ CA Cancer
J Clin, 2010; 60: 244-272.
7. Husband JE. Staging Bladder Cancer. Clinical
Radiology, 1992; 46: 153-159.
8. Jaume S, Ferrant M, Macq B, Hoyte L,
Fielding JR, Schreyer A et al. Tumor
detection in the bladder wall with a
measurement of abnormal thickness in CT
scans Transactions On Biomedical
Engineering; 2003; 50: 383-390.
9. Chen YK, Ding HJ, Su CT, Shen YY, Chen
LK, Liao AC et al. Application of PET and
PET/CT Imaging for Cancer Screening’,
Anticancer Research; 2004; 24: 4103-4108.
10. Denkhaus H, Crone-Münzebrock W, Huland
H. Noninvasive ultrasound in detecting and
staging bladder carcinoma. Urologic
radiology; 1985; 7: 121-131.
11. Caruso G, Salvaggio G, Campisi A, Melloni
D, Midiri M, Bertolotto M & Lagalla R.
Bladder Tumor Staging: Comparison of
Contrast-Enhanced and Gray-Scale
Ultrasound. AJR, 2010; 194: 151-156.
12. Akmangit I, Lakadamyali H, Oto A, Ozen H,
Akhan O, Besim A. Staging of urinary bladder
tumors with CT and MRI’. Tani Girisim
Radyol. 2003; 9: 63-9.
13. Tubin M, Thurston W, Wilson SR. In
Diagnostic Ultrasound, Eds. Rumack CM,
Wilson SR, Charboneau JW, Levine D,
Mosby USA, 4th edn, 2005; l l(1): 359-370.
14. Berlac PA and Holm HB; Bladder tumor:
Abdominal ultrasound and urine cytology. The
J. Urol, 1992; 10(2): 1510-1520.
15. Blake MA & Kalra MK. Imaging of urinary
tract tumors. Cancer Treat Res, 2008; 143:
299-317.
16. Stamatiou K, Papadoliopoulos L, Dahanis S,
Zafiropoulos G, Polizois K. The accuracy of
ultrasonography in the diagnosis of superficial
bladder tumors in patients presenting with
hematuria’. Ann Saudi Med, 2009; 29(2): 134–
137.
Bangladesh Journal of Radiology and Imaging Vol. 23(1): January 2015
18
Role of Diffusion Weighted MRI in Evaluation of
Acute Ischemic StrokeSHARZIA ASMA–UL HOSNA1, SALAHUDDIN AL-AZAD2, ENAYET KARIM3, MAHBUBA SHIRIN4,
BISHWAJIT BHOWMIK4, SYEEDA SHOWKAT4, SHAILA JABEEN6, KAZI ZAHRUL HAQUE7
1. Consultant Radiologist, LAB AID Specialized Hospital, Dhaka. 2. Professor, Department of Radiology & Imaging,
BSMMU, Dhaka. 3. Professor & Chairman, Department of Radiology & Imaging, BSMMU, Dhaka 4.Associate
Professor, Department of Radiology & Imaging, BSMMU, Dhaka. 5. Assistant professor, Department of Radiology
& Imaging, East west medical college, Dhaka. 6. Medical officer, Mugda Medical college and Hospital.
Abstract:
This cross sectional study was carried out in the
department of Radiology and Imaging of
Bangabandhu Sheikh Mujib Medical University,
Dhaka, to establish diagnostic usefulness of
diffusion weighted MRI in evaluation of acute
ischaemic stroke & to assess the efficacy of diffusion
weighted MRI in the diagnosis of acute ischaemic
stroke. For this purpose, a total of 72 patients who
were clinically diagnosed as ischemic stroke within
36 hours of onset of symptom & who underwent
MRI in the department of Radiology & Imaging
were enrolled. In this present study it was observed
that almost one third (32.5%) patients were in 6th
decade and the mean age was found 60.9 ±11.1
years. This study also showed that acute Ischemic
stroke is predominant in male subject accounting
for two third (65.3%) patients and rest one third
(34.7%) was female. Diffusion restriction was found
in 65(90.3%), hyper intensity on FLAIR found in
60(83.3%) and hyper intensity on T2WI was found
in 49(68.1%).
Key words: Acute ischemic stroke, DWI (Diffusion
Weighted Image)
Introduction:
Stroke is defined as the rapid appearance of a non-
convulsive, non-traumatic focal deficit of brain
function, most commonly a hemiplegia with or
without signs of focal higher cerebral dysfunction
(such as aphasia), hemi sensory loss, and visual
field defect or brain-stem deficit1. Acute ischemic
stroke is one of the leading causes of death and
disability worldwide2. In stroke patients 30% to
60% of the ischemic lesions are still invisible in
the acute stage. During the first 24 hours after an
ischemic stroke, proton density weighted (PDW)
and T2W MRI have 20% to 30% false-negative
results3. Cytotoxic edema develops minutes after
onset of acute cerebral ischemia and causes a
restriction of microscopic proton diffusion. In
diffusion-weighted MRI, this decrease in water
diffusion is presumably reflected as a decrease of
the apparent diffusion coefficient (ADC) on ADC
trace maps, which is visualized as a hyper intensity
on the diffusion-weighted images (DWI)4. In
humans, ischemic changes were detected with DWI
as early as 2 to 6 hours after onset of symptoms
(5%)5. Treatment protocols previously relied on
non-contrast computed tomography (NCCT)6.
Diffusion-weighted imaging (DWI) is a technique
based on magnetic resonance imaging (MRI) that
may be more sensitive and specific for acute
cerebral ischemia than NCCT 7.
Material & methods:
This cross sectional study was carried out in the
Department of Radiology and Imaging of BSMMU,
Dhaka from January 2014 to December 2015. Total
72 patients of age range of 45-85 years were
enrolled in this study. Patients clinically diagnosed
as acute ischemic stroke & came to our departmentwillingly to do MRI of brain according to clinicianadvice, were enrolled in the study. A writteninformed consent was obtained from each patient.Data was collected in a pre-designed structureddata collection sheet. MRI of brain was obtainedon 1.5T machine (Avanto Magnatom, Siemens)using T1WI, T2WI (TR-3280, TE-96), FLAIR (TR-410, TE-8.4) & DWI (TR-3300, TE-118) two
dimensional fast spin echo multi-slice technique.
Image was reviewed by two experienced
radiologists only receiving clinical information.
BANGLADESH JOURNAL OF RADIOLOGY AND IMAGING 2015; VOL. 23(1): 19-24
Image analysis included detection of altered signal
changes in T1, T2, FLAIR and diffusion restriction
in DW images. Anatomic location of the signal
change and others evidence of ischaemia were also
noted. Statistical analyses were carried out by
using the Statistical Package for Social Sciences
version 16.0 for Windows (SPSS Inc., Chicago,
Illinois, USA). The measure of agreement between
demographic variables was done by Kappa test. A
p-value <0.05 were considered significant.
Result
Total 72 patients who were clinically diagnosed as
ischemic stroke within 36 hours of onset of
symptom were enrolled in this study. It was
observed that more than one third (36.1%) patients
belonged to age group 51-60 years. The mean age
was found 60.9 ±11.1 years. Almost two third
47(65.3%) patients were male and 25(34.7%) were
female. More than half (55.60%) of the patients
had duration of symptoms between 6-12 hours. The
mean duration of symptoms was found to be 14.3
±7.3 hours. More than two third 50 (69.4%) patients
had speech disturbance, 45 (62.5%) had
hemiparesis/hemiplegia, 42 (58.3%) had impaired
consciousness, 30(41.7%) had vomiting, 29 (40.3%)
had headache/vertigo and 25 (34.7%) had cranial
nerve palsy. Out of all subject, it was observed
that 40 (55.6%) patients was found to have high
cholesterol, 17 (23.6%) had normal cholesterol and
15(20.8%) had low cholesterol. It was observed that
majority 48(66.7%) patients had more than one site
of infarction, 60(83.3%) had large size infarcts,
32(44.4%) involved the capsulo-ganglionic region
and in 40 (55.6%) patient it was MCA territory
infarction. Routine MRI showed normal signal
intensity on T2WI in 23(31.9%) patients, edema/
sulcal effacement in 18(25.0%) patients, and T2W
hyperintense in 31(43.1%) patients. Signal
intensity on FLAIR was normal in 12 (16.7%)
patients and hyper intense in 60 (83.35%) patients.
In DWI, diffusion restriction was found in 65
(90.3%) patients and no restriction was found in
07 (9.7%) patients. Diffusion restriction was found
in DWI in 65 (90.3%) patients, hyper intensity on
FLAIR was found in 60 (83.3%) patients and hyper
intensity on T2W was found in 49 (68.1)% patients.
Table I
Distribution of the study patients by duration of
symptoms (n=72)
Duration of symptoms Number of Percentage
(hours) patients
6-12 40 55.6
13-24 25 34.7
24-36 7 9.7
Mean±SD 14.3±7.3
Range (min, max) 6,36
Table II
Distribution of the study patients by stroke
profile (n=72)
Stroke profile No. of patients Percentage
Number of infarction
At single site 24 33.3
More than one 48 66.7
Size (cm)
Lacunar 12 16.7
Large 60 83.3
Location
Capsuloganglionic 32 44.4
Occipital region 14 19.4
Parieto temporal 6 8.3
Thalamic 5 6.9
Brainstem 7 9.7
Mixed 8 11.1
Vascular territory
ACA territory 18 25.0
infarction
MCA territory 40 55.6
infarction
PCA territory 14 19.4
infarction
Mass effect
Present 40 55.6
Absent 32 44.4
Bangladesh Journal of Radiology and Imaging Vol. 23(1): January 2015
20
Table III
Distribution of the study patients by routine MRI
findings (n=72)
Routine MRI No. of Percentage
findings patients
Signal intensity on T2W
Normal 23 31.9Hyper intense 31 43.1Oedema/sulcal 18 25.0effacement/muss effect
Signal intensity on FLAIRNormal 12 16.7
Hyper intense 60 83.3
Table IV
Distribution of the study patients by diffusion
weighted MRI (n=72)
MRI Number of patients Percentage
Present 65 90.3
Absent 07 9.7
Table V
Total number of stroke patients detected by DWI,
FLAIR and T2W (n=72)
Sequence Number of Percentage
patients
DW MRI 65 90.3
FLAIR 60 83.3
T2W 49 68.1
Table VI
Association between diffusion weighted MRI and
FLAIR evaluated by acute ischaemic stroke
(n=72)
FLAIR
DW MRI Present Absent
n % n %
Present 60(a) 100.0 5(b) 65
Absent 00(c) 0.0 7(d) 07
Total 60 12 72
s=significant
Measures of agreement Kappa Value 0.510, p value
0.001s
Kappa value is near to 1 that indicates goodagreement.
The above table shows the association between
dif fusion weighted MRI and FLAIR in
evaluation of acute ischaemic stroke. The
results of the two modalities (diffusion
weighted MRI and FLAIR) analysis found Kappa
value = 0.510 with p value <0.05. This measure
of agreement is statistically significant with
moderate agreement between dif fusion
weighted MRI & FLAIR in evaluation of acute
ischaemic stroke.
Fig.-1: DWI MRI of a patient, showing diffusion
restriction at right capsuloganglionic region- Acute
infarct at MCA territory
Role of Diffusion Weighted MRI in Evaluation of Acute Ischemic Stroke Sharzia Asma–Ul Hosna et al
21
Discussion
This cross-sectional study was carried out with an
aim to assess the usefulness of diffusion weighted
MRI in the diagnosis of acute ischaemic stroke. A
total of 72 patients clinically diagnosed as ischemic
stroke underwent MRI in the department of
Radiology and Imaging, Bangabandhu Sheikh
Mujib Medical University, Dhaka were included
in this study. Clinically diagnosed patients of acute
ischaemic stroke presented within first 36 hours
of onset of symptoms were included in the study.
The present study findings were discussed and
compared with previously published relevant
studies.
In this present study it was observed that almost
one third (32.5%) patients were in 6th decade and
the mean age was found to be 60.9±11.1 years.
Similarly, van Everdingen et al.3found the mean
age of 64 years with range from 36 to 85 years,
which closely resembled the present study. In this
present study it was observed that acute Ischemic
stroke is predominant in male subject, where
almost two third (65.3%) patients were male and
34.7% were female.
In this current study it was observed that 55.6%
patients had duration of symptoms between 6-12
hours and the mean duration of symptoms was
found to be 14.3±7.3 hours. Similarly, Baird et al7
found patients with acute ischemic stroke within
3 hours of the onset of symptoms. Pure motor
hemiparesis is the second most frequent syndrome.
In this series it was observed that 73.75% patients
had speech disturbance followed by 70.0%
hemipersis/hemiplegia, 60.0% impaired
consciousness, 51.25% vomiting, 48.75% headache/
vertigo and 41.25% cranial nerve palsy.
In this current study it was observed that majority
48 (66.7%) patients had more than one site of
infarction, 60 (83.3%) had large size, 32 (44.4%)
involved the capsulo-ganglionic region, 40 (55.6%)
had MCA territory infarction. Baird et al7 found
that in 43.0% of patients acute DWI lesion was
smaller than the final infarct volume measured
on T2-weighted images beyond 7 days.
Fig.-3: Axial T1W, T2W, FLAIR and Diffusion restricted MRI of the same patient, showing acute infarct
at left temporo-parieto-occipital region (MCA and PCA territory)
Fig.-2: Axial T1W, T2W, FLAIR and Diffusion restricted MRI of the same patient, showing acute infarct
in the area at splenium of corpus callosum
Bangladesh Journal of Radiology and Imaging Vol. 23(1): January 2015
22
In ischemia, there is net movement of water into
the brain tissue. This is the basis of the increased
T2 signal in MRI in first few days after stroke8. In
this series it was observed that signal intensity on
T2W was normal was in 31.25%, oedema/sulcal
effacement/mass effect in 25.0% and hyper intense
in 43.75%. Regarding the signal intensity on
FLAIR, it was found normal in 16.25% and hyper
intense in 83.75%.
In this study it was observed that diffusion
restriction was found in 65(90.3%) and no
restriction was found in 7(9.7%). Similarly,
Warach10 found 92.0% patients had a diffusion
restriction in MRI. In another study Lansberg et
al12 identified at least one acute lesion on the DWI/
ADC sequence in 94% of patients who experienced
a stroke.9
In this present study it was observed that Diffusion
restriction was found in 65(90.3%), hyper intensuty
on FLAIR found 60 (83.3%) and hyper intensity on
T2W was found in 49 (68.1)%.van Everdingen et
al.3 reported that all but one of the infarcts on
follow-up MRI were depicted as a hyper intense
lesion on DWI, whereas with T2W or PDW
imaging, 29.0% and 20.0% of lesions were not found
in the early stage10.
In this series it was observed that a total 67
positive cases of acute ischaemic stroke evaluated
by FLAIR, out of which 97.0% positive for acute
ischaemic stroke and 3.0% negative for acute
ischaemic stroke evaluated by diffusion weighted
MRI. A total of 13 negative cases of acute ischaemic
stroke evaluated by FLAIR, out of which 53.8%
positive for acute ischaemic stroke and 46.2%
negative for acute ischaemic stroke evaluated by
diffusion weighted MRI. The results of the two
modalities (diffusion weighted MRI and FLAIR)
analysis found Kappa value = 0.511 with p value
<0.05. This measure of agreement is statistically
significant with moderate agreement (Kappa value
belonged to 0.41 – 0.60) between diffusion weighted
MRI & FLAIR in identification of acute ischaemic
stroke. van Everdingen et al3 observed a total of
45 infarcts during the first 60 hours after stroke,
more lesions were detected on the DWI scans (98%)
than on the T2W images 11.. Lansberg et al. study
demonstrates some of the advantages of adding
DWI to a conventional MRI protocol for the
evaluation of stroke in consecutive patients who
underwent scanning within 48 hours after symptom
onset12. In another study, Gonzalez et al. 13
compared DWI with T2W and PDW MRI in 14
patients who experienced a stroke and in 8 control
patients. They concluded that DWI is more
accurate than T2W and FLAIR MRI for diagnosing
stroke in the very early phase13.
Conclusion
This study showed that diffusion weighted MRI is
a useful diagnostic modality in the diagnosis of acute
ischaemic stroke, followed by FLAIR and T2WI and
it would be worthy to note here that diffusion
weighted MRI can be used as a reliable tool for
diagnosing acute ischemic stroke.
References
1. Bamford J, 1992, ½Clinical examination in
diagnosis and sub-classification of stroke¼,
Lancet, vol. 339, pp. 400-4.
2. Dubey P, Pandey S and Moonis G 2013, Acute
Stroke Imaging: Recent Updates’, Stroke
Research and Treatment, vol. 2013, p. 1-6.
3. van Everdingen KJ, van der Grond J, Kappelle
LJ, Ramos LMP and Mali WPTM, 1998,
‘Diffusion-Weighted Magnetic Resonance
Imaging in Acute Stroke¼, Stroke, vol. 29,
pp. 1783-90.
4. Reith W, Hasegawa Y, Latour LL, Dardzinski
BJ and Sotak CH 1995, ‘Multi slice diffusion
mapping for 3-D evolution of cerebral
ischemia in a rat stroke model’, Neurology,
vol. 45. pp. 172–7.
5. Marks MP, de Crespigny AJ, Lentz D,
Enzmann DR, Albers GW, and Moseley ME,
1996, ½Acute and chronic stroke: navigated
spin-echo diffusion-weighted MR imaging¼,
Radiology, vol. 595, pp. 403-08.
6. Davis DP, Robertson T and Imbesi SG,
½Diffusion-weighted magnetic resonance
imaging versus computed tomography in the
diagnosis of acute ischemic stroke¼, J Emerg
Med, vol. 31, no. 3, pp. 269-77.
Role of Diffusion Weighted MRI in Evaluation of Acute Ischemic Stroke Sharzia Asma–Ul Hosna et al
23
7. Baird AE, Benfield A, Schlaug G, Siewert B,
Lovblad K and Edelman RR et al. 1997,
½Enlargement of human cerebral ischemic
lesion volumes measured by diffusion-
weighted magnetic resonance imaging, Ann
Neuro, vol. 41, pp. 581-89.
8. Silva GS, Koroshetz WJ, Gonzalez RG, and
Schwamm LH, 2011, ½Causes of Ischemic
Stroke¼, Springer-Verlag Berlin Heidelberg,
pp. 25-42.
9. Vidarsson L, Thornhill RE, Liu F, Mikulis DJ
and Kassner A 2009, ½Quantitative
permeability magnetic resonance imaging in
acute ischemic stroke: How long do we need
to scan ?, Magn reson imaging, vol 27,
pp.1216-22
10. Warach S, Gaa J, Siewert B, Wielpolski P and
Edelman RR, l995, ½Acute human stroke
studied by whole brain echo planar diffusion
weighted MRI¼, Ann NeuroI, vol. 37, pp. 231-
41.
11. von Kummer R, Allen KL, Holle R, Bozzao L,
Bastianello S and Manelfe C et al. 1997,
½Acute stroke: usefulness of early CT findings
before thrombolytic therapy¼, Radiology, vol.
205, pp. 327-33.
12. Lansberg MG, Norbash AM, Marks MP, Tong
DC, Moseley ME and Albers GW, 2000,
½Advantages of Adding Diffusion-Weighted
Magnetic Resonance Imaging to Conventional
Magnetic Resonance Imaging for Evaluating
Acute Stroke FREE¼, Arch Neurol, vol. 57,
no. 9, pp. 1311-6.
13. Gonzalez, RG, Schaefer, PW and Buonanno,
FS et al. 1999, ½Diffusion-weighted MR
imaging: diagnostic accuracy in patients
imaged within 6 hours of stroke symptom
onset¼, Radiology, vol. 210, pp. 155-62.
14. Bryan RN, Levy LM, Whitlow WD, Killian
JM, Preziosi TJ and Rosario JA, 1991,
½Diagnosis of cerebral infarction: comparison
of CT and MRI imaging¼, Am J Neuroradiol.
vol. 12, pp. 611-20.
15. Brott T, Marler JR, Olinger CP, Adams HP,
Tomsick T and Barsan W et al. 1989,
½Measurements of acute cerebral infarction:
lesion size by computed tomography¼ Stroke,
vol. 20, pp. 871–5.
Bangladesh Journal of Radiology and Imaging Vol. 23(1): January 2015
24
Abstract:
Introduction: Pituitary adenoma constitutes 10%
of all intracranial tumors. This study highlights
the role of MRI in evaluating Pituitary adenomas.
Methodology: This cross sectional observational
study was carried out in the Radiology and imaging
department of Sir Salimullah medical College &
Mitford Hospital, Dhaka medical College &
Hospital and National Institute of Neuroscience,
Dhaka from January 2014 to December 2015.
Results: Among 56 patients, Pituitary macro-
adenoma in 34 patients (60.72%), micro-adenoma
in 16 patients (28.57%), meningioma in 3 cases
(5.35%), craniopharyngioma in 1 case (1.78%) &
pituitary cyst in 2 cases (3.57%) were diagnosed by
MRI. Of the 34 MRI diagnosed macro-adenoma
cases, 4 of them were not confirmed by
histopathology. So, 30 cases were true positive
cases. Out of 56 patients rest 22 cases were
diagnosed by MRI as other than macro-adenoma
diagnosed by MRI. Histopathology confirmed that
20 were other than macro-adenoma and thus they
were true negative cases. Among 16 MRI diagnosed
cases, 14 cases were confirmed as micro-adenoma
by histopathology, were true positive cases. The
other 2 cases were not confirmed by histopathology
and thus were false positive cases. Of 40 cases of
other than micro-adenoma which were confirmed
by MRI, one was confirmed as Pituitary micro-
adenoma by histopathology and remaining 39 were
other than pituitary micro-adenoma by
Role of MRI in the Evaluation of Pituitary
Adenomas with Histopathological ComparisonSNIGDHA SARKER1, FARID AHMED2, BIBEKANANDA HALDER3, SUKHOMOY KANGSHA
BANIK4, MD RUED HOSSAIN5, SWATI MUNSHI6, ROWNAK AFRIN7,
MOHAMMAD SAZZAD HOSSAIN8
1.Assistant Professor, Department of Radiology & Imaging, NITOR, Dhaka, 2. Professor & Former Head of Dept.,
Department of Radiology and Imaging, Sir Salimullah Medical College, Dhaka. 3. Associate Professor, Department
of Radiology and Imaging, Sir Salimullah Medical College, Dhaka. 4. Professor, Department of Neonatology, Sir
Salimullah Medical College, Dhaka. 5. Associate Professor& head of the department, Department of Radiology and
Imaging, Sir Salimullah Medical College, Dhaka. 6. Specialist, Department of Radiology and Imaging, Square
Hospitals Ltd. 7. Assistant Professor, Institute of nuclear medicine and allied sciences, Dhaka, 8. Assistant
Professor, Department of radiology & Imaging, Sir Salimullah Medical College, Dhaka.
histopathology. They were false negative and true
negative respectively. Sensitivity of MRI in the
diagnosis of macro-adenoma was 93.75%,
Specificity was 83.33%, positive predictive value was
88.24%, negative predictive value was 90.91% and
accuracy was 89.29%. Sensitivity of MRI in the
diagnosis of micro-adenoma was 93.33%, specificity
95.12% positive predictive values are 87.5% negative
predictive values 97.5% and accuracy 94.64%.
Introduction:
Pituitary gland plays a central role in body growth,
metabolism and reproductive function. The
pituitary gland is a small, oval-shaped gland found
in the pituitary fossa, below the optic nerve. A
number of diseases that affect the pituitary-
hypothalamic axis can have profound clinical
endocrinological as well as neurological
consequences.1 Pituitary adenomas represent from
10% to 25% of all intracranial neoplasms and
between one third and one half of all sellar /
juxtasellar masses.2 Pituitary adenoma up to 10
mm in diameter is called microadenoma and
adenoma larger than 10 mm is called a
macroadenoma. Radiologically macroadenoma are
approximately twice as common as pituitary
microadenomas. In addition, pituitary adenomas
may be distinguished anatomically as intra-
pituitary, intra-sellar, diffuse, and invasive.3
Pituitary tumors can cause problems by: excessive
hormone production, local effects of the tumors,
BANGLADESH JOURNAL OF RADIOLOGY AND IMAGING 2015; VOL. 23(1): 25-29
or inadequate hormone production by the
remaining pituitary gland. The most characteristic
presenting features of pituitary adenomas include
inappropriate pituitary hormone secretion and
visual field deficits. Approximately three fourth of
the patient with pituitary adenoma manifest with
symptoms of hormone excess, the remainder have
clinical findings referable to tumor mass effect.4
The sellar region is the site of different pathological
entities arising from the pituitary and adjacent
anatomical structures including brain, blood
vessels, nerves and meninges. Among all these
entities, pituitary adenomas are the most common.
Prevalence of pituitary adenomas was 14.4% in
postmortem studies and 22.2% in radiological
studies, with an overall estimated prevalence of
16.9%.5
MR imaging of pituitary is important not only in
confirming the diagnosis of pituitary lesions but
also in determining the differential diagnosis of
other sellar lesions. Macroadenomas are usually
of relatively lower signal than normal brain on
T1WI and of higher signal on T2WI. Regions of
even lower signal on T1WI and higher signal on
T2WI, usually represent cysts when rounded and
circumscribed and necrosis when more irregular.
On Post contrast study shows delayed strong
inhomogeneous enhancement. Necrosis,
hemorrhage and cyst formation are common in
large adenomas.
Nearly 80%-90% of microadenomas are
hypointense to normal gland on T1WI & 30% -
50% is hyperintense on T2WI. Although most
adenomas are detected on non-enhanced MRI,
microadenomas may become visible only after
contrast injection (dynamic contrast study).6 On
post contrast examination: Focal mass that
enhance less rapidly and less intensely than
normal gland & delayed scan shows homogenous
enhancement of mass lesion.
Methodology:
This cross sectional observational study was
carried out in Radiology and imaging department
of Sir Salimullah Medical College & Mitford
Hospital (SSMC & Mitford hospital), Dhaka Medical
College & Hospital (DMCH) & National Institute
of Neuroscience Hospital (NINSH), Dhaka from
January 2014 to December 2015 after approval
from ethical committee. Purposive non random
sampling technique was carried out in this study.
All the patients with clinically suspected pituitary
adenoma of SSMC & Mitford Hospital, DMCH &
NINSH, Dhaka sent for MRI to Department of
Radiology and Imaging of respective institutes
during the study period were included as study
population. MRI scan of brain was performed in
all cases. With informed consent, only operated
cases were included & histopathological reports
were collected with MRI scan findings. All this
information was collected in predesigned
structured data collection sheets.
Pituitary macroadenoma —Axial Scan (Pre-contrast)
Pituitary macroadenoma —Saggital scan (Post-contrast)
Pituitary microadenoma --(Coronal scan (Post contrast)
Bangladesh Journal of Radiology and Imaging Vol. 23(1): January 2015
26
Result:
The main objective of the study was to establish
the role of MRI in detection of pituitary adenoma.
56 purposively selected patients were selected for
this cross sectional study. The age range of the
patient was 21-72 years. Mean ± SD of age of the
patients was 35.2 ± 11.42 years. Out of 56 patients,
the maximum 26(46.43%) patients were between
31-40 years. Among them 24 (42.86%) were male
and 32 (57.14%) were female with a male to female
ratio of 3:4.
The most common presenting feature of the
patients was headache (92.88%), followed by
vomiting (46.42%). 35.71% patient presented with
secondary amenorrhea, 33.93% patients
complained of visual disturbances & 12.5%
patient presented with convulsion. 7.14%
presented with acromegaly, and 5.36% with
polyuria, polydipsia.
Table I
Distribution of cases according to involved
location of sellar regions:
Frequency %
(n=56)
Intra-sellar. 18 32.14
Intra-sellar with supra-sellar 33 58.93ExtensionIntra-sellar with supra-seller 5 8.93& Para sellar extension
Total 56 100
Table II
Distribution of different morphological
appearance of pituitary adenoma
Morphology Frequency Percentage
(n=56)
Hemorrhage 13 23.21
Necrosis 12 21.43Cyst 5 8.92
Table III
Distribution of patients according to the MRI signal intensity of the tumor
Name of the Imaging Hypo Hyper Iso Mixed Total
tumor Sequence intense intense intense intensity %
Macroadenoma T1WI 07(20.59%) 13(38.82%) 10(29.41%) 04(11.76%) 100
T2WI 00 22(64.70%) 08(23.53%) 04(11.76%) 100
Microadenoma T1WI 10(62.5%) 00 06(37.5%) 00 100
T2WI 05(31.25%) 01(6.25%) 10(62.5%) 00 100
Other tumors of T1WI 04(66.67%) 00 02(33.33%) 00 100
sellar region T2WI 00 03(50%) 03(50%) 00 100
Among 56 patients, 50 were diagnosed by MRI as pituitary adenoma, 34 of which were macroadenoma,and 16 were microadenoma. 03(Three) tumors were diagnosed as meningioma, 01(One) ascraniopharyngioma and 2 (Two) as pituitary cysts.
Table IV
Distribution of the seller lesion as per MRI findings.
MRI diagnosis Frequency (n=56) Percentage
Macroadenoma 34 60.72
Microadenoma 16 28.57
Other tumors of sellar region 06 10.71
Total 56 100
Role of MRI in the Evaluation of Pituitary Adenomas with Histopathological Comparison Snigdha Sarker et al
27
Among 56 patients who underwent MRI
examination, pituitary Adenoma were found in 50
patients (89.29%), Pituitary macroadenoma in 34
patient (60.72%), Pituitary microadenoma in 16
patients (28.57%). Remaining 03 cases (5.35%) were
diagnosed as meningioma, 01 case (1.78%) as
craniopharyngioma & 02 (3.57%) cases as pituitary
cyst.
Table V
Distribution of the seller lesion as per
histopathological Diagnosis.
Histopathological Frequency Percentage
diagnosis
Macro adenoma 32 57.14
Micro adenoma 15 26.79
Other tumor of sellar region 09 16.07
Total 56 100
56 patients were operated and histopathological
examination was done. Histopathologically 32
(57.14%) patients were diagnosed as
macroadenoma and 15 (26.79%) patients were
diagnosed as micro adenoma, 9 (16.07%) patients
were histopathologically diagnosed as other tumor
of sellar region.
MRI diagnosed 34 patients as macroadenoma of
which 02 were not confirmed by histopathology
and out of 16 MRI diagnosed microadenoma 01 was
histopathologically not confirmed as same tumor.
So out of 56 operated patient 47 patients were
histopathologically positive of pituitary adenoma,
3 cases were MRI positive but histopathologically
negative. So, 3 cases were false positive.
Table VI
Showing validity test of MRI in the diagnosis of
Pituitary Microadenoma
Sensitivity 93.33%
Specificity 95.12%
Positive predictive values 87.5%
Negative predictive values 97.5%
Accuracy 94.64%
Sensitivity of MRI diagnosis to microadenoma was
93.33%, specificity 95.12% positive predictive
values are 87.5% negative predictive values 97.5%
and accuracy 94.64%.
Table VII
Showing validity test of MRI in the diagnosis of
Pituitary Macroadenoma
Sensitivity 93.75%
Specificity 83.33%
Positive predictive value 88.24%
Negative predictive value 90.91%
Accuracy 89.29%
Sensitivity of MRI in the diagnosis of
macroadenoma was 93.75%, Specificity was
83.33%, positive predictive value was 88.24%,
negative predictive value was 90.91% and accuracy
was 89.29%.
Discussions:
MR imaging is the optimal imaging technique for
assessing the sellar or suprasellar region. High-
resolution imaging is required to evaluate the
normal anatomy and to detect subtle tumors such
as microadenomas. The current cross sectional
study was carried out among 56 patients; age
ranging from 21 to 72 years. The maximum
number of the patients was between 30-40 years.
Mean ± SD of age of the patients was 35.2 ± 11.42
years. Out of 56 patients, the maximum 26(46.43%)
patients were between 31-40 years. Out of 56
patients, 24 (42.86%) were male and 32 (57.14%)
were female. Male to female ratio was 3:4. These
findings are almost consistent with the study done
by Gruppetta et al .7
In 32% cases, tumor were confined to intrasellar
region, in 58% cases tumor extended to suprasellar
region & in 9% cases tumor extended further more.
Dahnert9 described supraseller & para seller
extension of tumor up to 67% which is similar to
current study.8
Among 56 patients, 50 were diagnosed by MRI as
pituitary adenoma, 34(60.7%) of which were
macroadenoma and 16 (28.5%) were
microadenoma. 3 tumors were diagnosed as
Bangladesh Journal of Radiology and Imaging Vol. 23(1): January 2015
28
meningioma, 1 tumor as craniopharyngioma and
two as pituitary cysts. According to Dahnert9,
incidence of macroadenoma is 70-80% &
microadenoma is 20-30% which is similar to this
study.8
Morphologically in pituitary adenoma, hemorrhage
was found in 13 (23.21%) cases & necrosis and
cystic change which were 12(21.43%) and 5(8.92%)
respectively (Table-VI). These findings are
consistent with the study done by Walsh &
Couldwell.9Out of 34 patients of MRI diagnosed
macroadenoma, 02 were not confirmed by
histopathology and out of 16 MRI diagnosed
microadenoma 01 was histopathologically not
confirmed as same tumor. So out of 56 operated
patient 47 patients were histopathologically
positive of pituitary adenoma. 3 cases were MRI
positive but histopathologically negative.
Present study showed the sensitivity, specificity,
positive predictive value, negative predictive value
and accuracy of MRI in diagnosis of pituitary
microadenoma as 93.33%, 95.12%, 87.5%, 97.5%
and 94.64% respectively. Sensitivity, specificity,
positive predictive value, negative predictive value
and accuracy of MRI in diagnosis of pituitary
macroadenoma were 93.75%, 83.33%, 88.24%,
90.91% and 89.29% respectively.
Conclusion:
The present study revealed high sensitivity,
specificity and accuracy of MRI in detecting
pituitary adenoma. More importantly, MR imaging
scans can demonstrate the precise effect of the
tumor mass on the adjacent structures, particularly
those of the visual system and cavernous sinuses.
Thus MRI can be a useful imaging modality in the
diagnosis of pituitary adenoma.
References:
1. Chaudhary V and Bano S, ‘Imaging of the
pituitary: Recent advances’, Indian J
Endocrinology and Metabolism, 2011, vol.15
(Suppl 3), p 216-23.
2. Russell DS & Rubinstain J, Pathology of
tumors of the nervous system, 5th edition,
Williams and Wilkins, Baltimore, 1989, p. 389.
3. Kovacs K, Horvath E &Vidal S, ‘Classification
of pituitary adenomas’, J Neuro oncol, 2001,
vol. 54, no. 2, pp.121-7.
4. Levy A, ‘Pituitary disease: presentation,
diagnosis, and management’, J Neurol
Neurosurgery Psychiatry, 2004, vol. 75, no.
3, pp.47-52.
5. Ezzat S, Asa SL, Couldwell WT. et al , The
prevalence of pituitary adenomas: a
systematic review. Cancer 2004, 101613–19.
6. Sutton D, Stevens J & Miszkiel K,‘Intracranial lesions’, In Robinson, P, JenkinsJ, Whitehouse R, Allan PL, Wilde, P &Stevens JM, Textbook of Radiology andImaging , 7th edition, Elsevier Ltd, Churchill
Livingstone, 2003,Vol.2, p. 1751.
7. Gruppetta MI, Mercieca C & Vassallo J.,
Prevalence and incidence of pituitary
adenomas: a population based study in Malta.
Pituitary. 2013, Dec; 16(4):545-53.
8. Dahnert W, Radiology review manual,
Wolters Kluwer, Lippincott Williams &
Wilkins, New York, 2011.
9. Walsh MT & Couldwell WT, ,’Symptomatic
cystic degeneration of a clinically silent
corticotroph tumor of the pituitary gland’,
Skull Base, 2010, sep;20(5):367-370.
Role of MRI in the Evaluation of Pituitary Adenomas with Histopathological Comparison Snigdha Sarker et al
29
Abstract:
This Study was performed by duplex colour Doppler
ultrasonography to assess & compare blood flow in
the ophthalmic artery of patient with diabetic
retinopathy and normal subjects. This cross
sectional study was done on diabetic patients with
retinopathy and normal subjects in the department
of Radiology and Imaging, BIRDEM from June
2010 to May 2011. 80 patients were referred from
the department of ophthalmology, BIRDEM. 87 eyes
of 50 diabetic retinopathy subjects and 60 eyes of 30
reference subjects were enrolled in the study. Duplex
colour Doppler sonography was done in all study
groups including measurement of resistive index (RI)
of ophthalmic artery. The study showed that there
is a significantdifference between the RI values of
diabetic retinopathy study group and reference
group. The subjects of study group again divided
into subgroups for comparative study to evaluate
the severity of diabetes retinopathy. In the study it
was tried to establish that according to severity the
RI values of ophthalmic arteryin diabetic retinopathy
patients subsequently increased. Our results in this
study suggest that Duplex colour Doppler
sonography of ophthalmic artery to assess the
resistive index has the potential to provide useful
information about the hemodynamic changes in
patients with diabetic retinopathy and may be
triggered by increased resistive index in comparison
to reference subjects. But for any definite conclusion,
bigger appropriate study should be done.
Key words: Ophthalmic artery,Duplex colour
Doppler imaging, Diabetes, Retinopathy.
Duplex Colour Doppler Evaluation of Ophthalmic
Artery in Diabetic Retinopathy Patients and
Normal SubjectsNAFFISA ABEDIN1, AS MOHIUDDIN2, JAFREEN SULTANA3, ABDULLAH SHAHRIAR4,
MD ANISUR RAHMAN KHAN5, HASINA BEGUM6, MST. JESMIN ARA PARVEN7
MAHMUDA SULTANA8
1. Assistant Professor, Department of Radiology and Imaging, BIRDEM, 2. Professor and Head, Department of
Radiology and Imaging, BIRDEM, 3. Associate Professor, Department of Radiology and Imaging, BIRDEM, 4
Associate Professor, Department of Paediatric Cardiology, NICVD, 5. Associate Professor, Department of Radiology
& Imaging, Colonel Malek Medical college, Manikganj. 6. Associate Professor, Department of Radiology & Imaging,Dhaka Medical College Hospital, Dhaka, 7. Consultant (Radiology), Labaid Specialized Hospital, Dhanmondi,
Dhaka. 8. Assistant Professor, Department of Radiology & Imaging, Dhaka Community Medical College Hospital,
Dhaka.
Introduction:
Diabetes affects the body from head to toes; this
also includes eye. The most common and most
serious complication of diabetes is diabetic
retinopathy, which may result in poor vision or
even blindness. Retinopathy is the medical term
for damage to the tiny blood vessels (capillaries)
that nourish the retina.
A data from Statistical Department of BIRDEM
showed,total patient of diabetic retinopathy (from
1956-2006): 3,54,652. New cases: 21,948 and old
cases: 20,639: Percentage of Diabetic retinopathypatient came to Eye department of BIRDEM uptoNovember 2007: 28.3%.
Colour Doppler Imaging is a non-invasiveultrasonic method for qualitatively andquantitatively assessing blood flow velocityinformation1.
In ophthalmology, Colour Doppler Imaging is a
new method that enables us to assess the orbital
vasculature. It allows for simultaneous two
dimensional anatomical and Doppler evaluation of
haemodynamic characteristics of ophthalmic
artery in diabetic patients with ocular
involvement2.
The ophthalmic artery originates from internal
carotid artery and enters the orbital cavity through
optic canal. Average diameter of ophthalmic artery
where it crosses the optic nerve is 1.33 ± 0.33 mm.
Studies of retro bulbar haemodynamics of the
BANGLADESH JOURNAL OF RADIOLOGY AND IMAGING 2015; VOL. 23(1): 30-35
central retinal artery (CRA), short posterior ciliary
artery (PCA) and ophthalmic artery in patients
with retinopathy have already been performed3.
Although gray-scale ultrasound displays the
anatomy of orbit well, colour Doppler imaging
provides additional information regarding the
direction and velocity of blood flow.
Several features that make it a good modality for
evaluating the orbit includes: low cost, lack of
ionizing radiation, non-invasive nature of
technique, no use of iodinated contrast material
with its inherent nephrotoxicity and anaphylactic
risk, short examination time,cataract or intra
ocular hemorrhage do not hinder velocity
measurement, ability to measure velocity and
direction of blood flow in vessels that are not easily
studied by any other means4.
Changes in ophthalmic blood flow of eyes with
background retinopathy (BDR), proliferative
retinopathy (PDR) and ocular ischemic syndrome
(OIS) are analyzed by colour Doppler imaging5.
Classification of diabetic retinopathy
1) Non-proliferative diabetic retinopathy (NPDR)
2) Proliferative retinopathy (PDR)
3) Diabetic maculopathy
Some studies showed the role of colour Doppler
imaging in the retrobulbar vascular circulation in
diabetic retinopathy.
There was no significant difference in the indices
of right eyes compared to those of left eyes6.
Vmax,Vmin and RI were compared between normal
subjects and patients. RI was significantly higher
in patients with background retinopathy and
0.786±0.081 in patients with pre-proliferative or
proliferative retinopathy than in normal subjects
(0.728 ± 0.054)3.
Colour Doppler imaging used to determine
significant changes of blood flow velocity in the
ophthalmic artery compared with normal subjects
and the changes of blood flow velocity become
further significant considering the progression of
diabetic retinopathy7.
In contrast to fluorescein angiography, colour
Doppler imaging is non-invasive technique that
may be repeated in short intervals. Severe
complication of diabetic retinopathy such as
tractional retinal detachments and neovascular
membranes may be diagnosed without using
additional techniques8.
The current study was carried out to prove a
decrease in ophthalmic arterial diastolic blood flow
velocity and increased resistive index in diabetic
patients with retinopathy, which indicates increase
in peripheral vascular resistance and a decrease
in the diameter of ophthalmic artery in diabetic
patients.
This new technique can be applied, when standard
diagnostic procedures, e.g. fundus examination or
fluorescein angiography are impossible because of
cataract and vitreous hemorrhage in patients with
diabetic retinopathy. The purpose of this study is
to assess the diagnostic benefit of duplex colour
Doppler sonography in conjunction with gray scale
imaging (B scan) to detect the ophthalmic arterial
flow resistance in different stages of diabetic
retinopathy, which will be very informative for
ocular surgeons to modify the treatment plan.
Materials and Methods:
This cross-sectional study was attempted on 147
eyes of 80 subjects aged 27-65 years in the
department of Radiology and imaging, BIRDEM
from June 2007 to May 2008. Out of them 87 eyes
of 50 diabetic retinopathy patients were considered
study group and 60 eyes of 30 healthy subjects were
considered as reference group.
At first ophthalmoscopically diagnosed patients of
diabetic retinopathy were referred from
ophthalmology OPD, BIRDEM to our department
for colour Doppler imaging of eyes.
Selection of the patients
[A] Reference group
Inclusion criteria:Healthy adult volunteers aged
30-59 years with normal ophthalmoscopic findings
without history of any systemic disease or ocular
surgery.
Duplex Colour Doppler Evaluation of Ophthalmic Artery in Diabetic Retinopathy Patients Naffisa Abedin et al
31
[B] Study group
i) Inclusion criteria: Ophthalmoscopically
diagnosed cases of diabetic retinopathy.
ii) Exclusion criteria: Diagnosed cases with
associated glaucoma, hypertension, high grade
myopia, Age related maculopathy or the
patients with history of laser treatment or
intraocular surgery
Data collection and measurement
Before colour Doppler US examination proper
counseling and reassurance to the patient
regarding the examination procedure was done to
reduce their apprehension and to get full co-
operation.
A firm bed was used without pillow.
Each subject was placed recumbent with a 15o left
lateral tilt. Coupling gel was applied to the closed
eyelid and transducer placed on eyelid with gentle
pressure to eye to avoid artifacts. Gray scale
imaging was performed first to obtain an overview
anatomy of the orbit.
Ophthalmic arterial blood flow velocity was
assessed using CDI, an ultrasound technique that
combines B-scan gray scale imaging of tissue
structure,coloured representation of blood flow
based on Doppler shifted frequencies and pulsed
Doppler measurement of blood flow velocities.
Statistical analysis of data
Statistical analysis of the results was done by
computer software devised as the statistical
package for social scientist (SPSS). The results were
presented in tables. figures, diagrams etc. For
significant of differences unpaired ‘t’ test and
‘ANOVA’ tests were applicable. A ‘p’ value <0.05
was considered as significant.
Result:
This cross-sectional study was done to compare
the ophthalmic arterial resistive index (RI) in 60
eyes of 30 healthy non- diabetic individuals included
as reference group and 87 eyes of 50 patients with
diabetic retinopathy. All the subjects were divided
into three age groups, age ranging from 30 to 59
years.
The diabetic retinopathy was classified into two
groups, which were non-proliferative diabetic
retinopathy (NPDR) and proliferative diabetic
retinopathy (PDR). NPDR were subdivided into 3
sub-groups, named- mild NPDR. moderate NPDR
and severe NPDR. The mean peak systolic velocity
(PSV) of ophthalmic artery in control eye was 23.56
± 0.77 cm/sec (mean±SE) ranged 18.0-30.3 cm/sec
and mean peak systolic velocity (PSV) of ophthalmic
artery in diabetic retinopathy eye was 33.52± 0.71
ranged 27.5-42.5 cm/sec. The mean difference of
ophthalmic arterial peak systolic velocity (PSV) in
diabetic retinopathy eyes and reference eyes was
statistically significant (P<0.05) in unpaired t test.
The mean end diastolic velocity (EDV) in
ophthalmic artery of 60 control eyes were 7.44 ±
0.16 cm/sec (mean ± SE) ranged 6.5-8.8 cm/sec and
mean end diastolic velocity (EDV) in ophthalmic
artery of 87 diabetic retinopathy eyes were 5.76 ±
0.13 (mean ± SE) ranged 3.9-6.6. The mean
difference of ophthalmic arterial end diastolic
velocity (EDV) in diabetic retinopathy eye and
reference eye was statistically significant (p<0.05)
in unpaired t test. This result showed in table II.
Table-I
Comparison between mean peak systolic velocity (PSV) of 60 reference eyes and 87 diabetic retinopathy
eyes (n-147)
Peak systolic velocity (PSV) Mean ± SE Range p value
Reference group (n=60) 23.56 ± 0.77 18.0 - 30.3 0.001s
Diabetic retinopathy group (n=87) 33.52 ± 0.71 27.5 - 42.5
t value=10.99.df=145. p value=0.001
Bangladesh Journal of Radiology and Imaging Vol. 23(1): January 2015
32
The diabetic retinopathy eyes of 50 study patients
were classified into two groups according to
severity of disease. The mean resistive index (RI)
of mild non-proliferative diabetic retinopathy
(NPDR) group was 0.79±0.007 (mean ± SE) ranged
from 0.76-0.83, moderate non-proliferative diabetic
retinopathy (NPDR) group was 0.80.0.008 (mean ±
SE) ranged from 0.74-0.86 and severe non-
proliferative diabetic retinopathy (NPDR) group
was 0.83±0.005 (mean ± SE) ranged from 0.76-0.89.
The mean resistive index (RI) of proliferative
diabetic retinopathy (PDR) group was 0.88±0.006
(mean ± SE) ranged from 0.82-0.91. The difference
of resistive index (RI) among these groups were
statistically significant (p<0.05) in ANOVA test.
The mean ophthalmic arterial resistive index (RI)of 60 eyes of 30 reference subject was 0.68 ± 0.01(mean ± SE). ranged from 0.65-0.76 and meanresistive index (RI) of 87 eyes of 50 diabetic
Table-II
Comparison between mean end diastolic velocity (EDV) of 60 reference eyes and 87 diabetic retinopathy
eyes (n-147)
End diastolic velocity (EDV) Mean ± SE Range P value
Reference group (n=60) 7.44 ± 0.16 6.5-8.8 0.001s
Diabetic retinopathy group(n=87) 5.76 ± 0.13 3.9-6.6
t value=9.56, df=145. p value=0.001
Fig.-1: Bar diagram showing resistive index (RI)
value among the diabetic retinopathy eyes
according to severity of retinopathy(n=87).
retinopathy subjects was 0.82 ± 0.005 (mean ± SE).ranged from 0.76-0.91%. The mean difference ofresistive index (RI) was significantly (p<0.05) higherin diabetic retinopathy eyes in unpaired ‘t’ test.
a. Spectral Doppler flow patterns of ophthalmicartery of right eye in normal reference subject
b. Spectral Doppler flow patterns of ophthalmicartery of left eye in diabetic retinopathy subject.
Fig.-2: Spectral Doppler flow patterns of ophthalmic artery
Mean
Resi
stiv
e
Ind
ex (
RI)
Duplex Colour Doppler Evaluation of Ophthalmic Artery in Diabetic Retinopathy Patients Naffisa Abedin et al
33
Discussion:
Diabetic retinopathy is a complication of diabetes,
an impairment of blood sugar metabolism that
involves two phases. In the first or non-proliferative
phase, there was swelling and blockage of blood
vessels and loss of connective tissue cells that
surround the blood vessels. In the second or
proliferative phase, there is an over growth of new
vessels and connective tissue, which may result
in blindness. Diabetic retinopathy is the second
most common cause of blindness in the world under
age 65 years9.
Colour Doppler imaging is the most promising
modality that produces conventional gray-scale
ultrasound images along with information
regarding the direction and velocity of blood flow4.
Many authors have investigated the utility of
colour Doppler sonography to compare the blood
flow velocity of ophthalmic artery in diabetic
retinopathy eyes and normal reference eyes, where
diabetic retinopathy eyes have found significantly
higher resistive index (RI) in the ophthalmic
artery1.
The aim of this cross sectional study was to observe
the usefulness of non-invasive duplex colour
Doppler sonography of ophthalmic artery with
measurement of resistive index (RI) in patients of
diabetic retinopathy and to compare the findings
with those of normal reference subjects.
Ophthalmic arterial RI value of 0.78 or more
considered positive for diabetic retinopathy.
87 eyes of 50 diabetic retinopathy subjects were
recruited prospectively from the ophthalmology
OPD, BIRDEM and divided into two groups.
Patients were classified according to modified Airlie
house system. Ultimately a total of 87 eyes of 50
diabetic retinopathy subjects were included in the
study.
Among the 57 non-proliferative diabetic
retinopathy (NPDR) eyes (65.5%), 11 eyes (19.3%)
were found unilateral and 46 eyes (80.7%) were
found bilateral. However in proliferative diabetic
retinopathy (PDR) (34.5%), 02 eyes (6.7%) were
enrolled as unilateral retinopathy and 28 eyes
(93.3%) were enrolled as bilateral retinopathy. The
observation revealed that the frequency of bilateral
diabetic retinopathy (NPDR and PDR) were greater
than unilateral diabetic retinopathy.
Besides the main theme of the study to compare
the resistive index (RI) of diabetic retinopathy eyes
with normal reference eyes, some other
parameters were also observed, like complications
of diabetic retinopathy.
Observation found that in 87 eyes of diabetic
retinopathy, 02 eyes (2.3%) of mild NPDR, 05 eyes
(5.7%) of moderate NPDR and 07 eyes (8.0%) of
severe NPDR showed some complications. On the
30 eyes of proliferative diabetic retinopathy (PDR),
13 eyes (14.9%) observed complicatons.
In this study the mean differences of ophthalmic
arterial peak systolic velocity (PSV) in diabetic
retinopathy eyes and reference eyes was
statistically significant (p<0.05) in unpaired t-test.A
previous investigator Mackinnon et al.1(2000)
compared the mean PSV of ophthalmic artery in
diabetic retinopathy patient and reference group
and found there was significant difference of
ophthalmic arterial PSV in study and reference
groups.
The mean end diastolic velocity (EDV) of 87 diabetic
retinopathy eyes and 60 reference eyes was
statistically significant (p,0.05) in unpaired t-test.
This observation is supported by the study done
by Mendivilet al.2 (1995).
The study found the significant association between
RI and different forms of NPDR (i.e. mild.
moderate and severe). This observation was
supported by the study done by Gracner7 (2004),
who have found the ophthalmic arterial RI in
diabetic retinopathy group was significantly higher
than reference group and increased with the
severity of retinopathy. It indicates the necessity
of early control of diabetic retinopathy.
In this study the resistive index (RI) measured in
87 eyes of 50 diabetic retinopathy subjects, the
mean RI value was found (o.82 ± 0.005) (mean ±
SE) ranging 0.76-0.91 and the previous
investigators Arai et al.9 (1998) and Mendivil et al
(1995). who found the mean RI value of 0.86 ± 0.06
(mean ± SE) and 0.83 ± 0.04 (mean ± SE)
Bangladesh Journal of Radiology and Imaging Vol. 23(1): January 2015
34
respectively, all of which were above the reference
value of 0.78. Mean resistive index (RI) value found
in 60 eyes of 30 healthy subjects was 0.68 ± 0.01
(mean ± SE) ranging from 0.65-0.76 and the
previous investigator Arai et al. (1998) and Mendivil
(1995) discovered the mean RI value of ophthalmic
arteries in healthy control subject was 0.72 ± 0.06
(mean ± SE) and 0.70 ± 0.08 (mean ± SE)
respectively. None of these crossed the reference
value (0.69-0.78).
From the results of the present study, it was
conceived that none of the reference eyes displayed
an RI value greater than 0.78 and values higher
than this favoured the diagnosis of a diabetic
retinopathy. It thus could be concluded that colour
Doppler imaging (CDI) along with measurement
of resistive index (RI) is one of the accurate
diagnostic imaging tool for monitoring the
predictive power in identifying those at greater
risk of developing and progressing sight-
threatening diabetic retinopathy.
The resistive index of ophthalmic artery was
increased in diabetic retinopathy study group
compared to reference group. It was also
established that ophthalmic arterial resistive index
increases with the increment in the severity of
diabetic retinopathy. The results of this study are
compatible with those of other studies done earlier.
Conclusion:
Duplex colour Doppler sonography is a useful tool
for assessment of vascular resistance, From the
findings of present study it can be concluded that,
ophthalmic arterial resistivity index (RI) increases
in diabetic retinopathy in comparison to that of
healthy adult subjects, with normal
ophthalmoscopic findings. Degree of increment of
RI correlates with severity of retinopathy. Colour
Doppler imaging in adjunct with conventional gray
scale ultrasound give more information regarding
the direction and velocity of blood flow, which can
predict the haemodynamic changes in patients
with diabetic retinopathy more accurately.
References:
1. Mackinnon JR, Mckillop G, Brien O, Butt Z,
Nelson P.Colour Doppler Imaging of theocular circulation in diabetic retinopathy. Acta
ophthalmol Scand 2000; 78: 386-389.
2. Mendivil A, Cuartero V, Mendivil MP. Ocularflow velocities in patients with proliferativediabetic retinopathy and healthy volunteers.B J of ophthalmology 1995; 79: 413-416.
3. Tamaki Y, Nagahara M, Yamashita H,Kikuchi M. Blood velocity in the ophthalmicartery determined by colour Doppler imagingin normal subjects and diabetics, Jpn. J.
opthalmol,1993. 37: 385-392.
4. Belden CJ, Abbitt PL, Beadles KA. ColourDoppler US of the orbit. Radiographic,
1995.15: 589-608.
5. Ino-ue M, Azumi A, Yamamoto M. Ophthalmicartery blood flow velocity changes in diabeticpatients as a manifestation of macro-angiopathy. Acta ophthalmol. Scand 2000. 78:173-176.
6. Baydar S, Adapinar B, Kebapci N, Bal C,Topbas S. ‘Colour Doppler Ultrasoundevaluation of orbital vessels in diabeticretinopathy’ Australas Radiol 2007.51 (3):230-235.
7. Gracener T. ‘Ocular blood flow velocitydetermined by Colour Doppler Imaging indiabetic retinopathy, Ophthalmologica 2004,218, 237-242.
8. Goebel W,Lieb E, HO A, Sergott RC,Farhoumand R and Grehn F.Colour Dopplerimaging. A new Technique to Assess OrbitalBlood Flow in patients with DiabeticRetinopathy, Invest Ophthalmol Vis C1995,36: 864-870.
9. Engerman RL. Pathogenesis of diabeticretinopathy. Diabetes 1989. 38: 1203.
10. Arai T, Numata K, Tanaka K,KibaT,Kawasuki S, et al. Ocular arterial flowhemodynamic in patients with diabetes
mellitus, J Ultrasound Med 1998.17:675-681.
Duplex Colour Doppler Evaluation of Ophthalmic Artery in Diabetic Retinopathy Patients Naffisa Abedin et al
35
Correlation of Mental Status of Elderly Subjects
With Cerebral White Matter T2 Hyperintensities
in MRINAFFISA ABEDIN1, NIRAJ REGMI2, ABU SALEH MOHIUDDIN3, ABDULLAH SHAHRIAR4,
MUHAMMAD IRFANUL ALAM5, NAYEMA RAHMAN6, HASHINA BILKISH BANU7
1. Assistant Professor, Department of Radiology and Imaging, BIRDEM. 2. Ex.MD Student, Department of
Radiology and Imaging, BIRDEM. 3. Professor and Head, Department of Radiology and Imaging, BIRDEM.4.Associate Professor, Department of Paediatric Cardiology, NICVD. 5. Resident Medical Officer, Department of
Radiology and Imaging, BIRDEM. 6. Assistant Professor, Department of Radiology and Imaging, BIRDEM.7.
Assistant Professor, Department of Physical Medicine, Shaheed Suhrawardy Medical College, Sher-e-
Banglanagar, Dhaka.
Abstract:
This cross-sectional study was carried out in the
department of Radiology and Imaging, BIRDEM,
Dhaka during the period of July, 2013 to June,
2015 with an aim to establish white matter changes
in brain of elderly subjects assessed by MRI scan
with their mental status.
A Total number of 80 consecutive subjects aged
more than 60 years were included in the study.
Non contrast MRI of the brain was performed and
subjects with white matter hyperintensities without
other identifiable lesions at brain MRI were
included. Those patients were than evaluated for
their mental status by mini mental status
examination (MMSE) protocol, which was assigned
a scoring system. A score of less than 24out of 30
was considered as decline of cognitive function. The
mean age of the subjects was 68.59 ± 7.249 years
with a range of 60 to 90 years.
White matter hyperintensities were either seen in
periventricular or subcortical locations. To evaluate
periventricular white matter hyper intensities,
frontal cap, bands and occipital caps were
evaluated and scoring system was assigned with a
range of 0 to 9.
36 out of 44 patients whose MMSE score was less
than 24 had a periventricular score of five or more
(81.18%). It was also noted that 24 out of 36
patients (66.66%) who’s MMSE score more than 24
had a periventricular score of less than five.
A significant negative correlation was found when
mini mental status examination score was
correlated with the extent of periventricular white
matter hyperintensity (r=-0.78; p<0.0001). When
MMSE score was separately correlated with
periventricular hyperintensities in the frontal,
occipital and band regions, a significant negative
correlation was found.
Key words: MRI hyperintensity, white matter,
mental status.
Introduction:
White matter hyperintensities (WMH) are areas
of focal and diffuse hyperintense signals visualized
radiologically on T2-weighted magnetic resonance
imaging (MRI). They are among the most
ubiquitous findings in older adults1. Cerebral white
matter lesions (WMLs) have been associated with
cognitive impairment in demented and non-
demented elderly subjects2.White matter lesions
are often found on MR scans of elderly people and
they are attributed to degenerative changes of long
penetrating arteries. A number of studies have
established that WMH burden (i.e., volume or
severity) is negatively associated with performance
across a range of cognitive tests, particularly those
involving executive functioning, processing speed
and attention1.
The white matter of the brain can be distinguished
into the area just under the cortex (subcortical)
and the area adjoining the ventricles
(periventricular). WMLs in these two regions may
affect cognition in different ways3.
Periventricular, but not subcortical WMLs, have
been related to atherosclerosis and cognitive
impairment has been related to periventricular
BANGLADESH JOURNAL OF RADIOLOGY AND IMAGING 2015; VOL. 23(1): 36-41
WMLs, but not to subcortical WMLs, illustrating
the importance of differentiating between WMLs
at different locations. The mechanisms underlying
these differences are not clear, but possibly the
vascular architecture of the periventricular area
is more vulnerable to damage than other white
matter areas3. However, there is also some
evidence that the subcortical white matter lesions
may be related to late onset depression4.
White matter lesions are considered to be present
if the lesions are hyperintense on both FLAIR and
T2 weighted images and not hypointense on T1
weighted images. The size of subcortical white
matter lesions is rated on hard copy according to
the largest diameter of one lesion within all slices
in which the lesion can be seen in categories of
(small <3 mm), medium (3-10 mm) or large lesions
(>10 mm). Periventricular white matter lesions
are rated semi-quantitatively per region: adjacent
to frontal horn (frontal capping), adjacent to lateral
wall of lateral ventricles (bands), and adjacent to
occipital horn (occipital capping) 4.
The mental status evaluation includes evaluation
of awareness and consciousness, behavior,
emotional state, content and stream of thought,
and sensory and intellectual capabilities.
The mini mental status examination (MMSE) canbe administered at the bed side and completed in10 minutes5. The Mini Mental State Examination(MMSE) is a simple assessment of cognitive
function in elderly subjects. A score of 23 or less is
commonly used to reflect cognitive impairment6.
In Bangladesh, the aging population is frequently
neglected. But the modern philosophy is that the
old must continue to take their share in the
responsibilities and in the enjoyment of the
privileges, which are an essential feature of
remaining an active member of the community.
So their mental status should be properly
evaluated and relevant organic cause should be
searched first. MRI of brain is an important
modality to assess degree of atrophy,
ventriculomegaly and white matter change.
Moreover it can also help to identify the organic
lesions, all of which may cause mental
abnormalities. The present study is designed to
observe the relation between mental statuses of
elderly persons with MRI white matter
hyperintensities.
Materials and Methods:
This cross sectional study was done on 80 subjects
in the department of Radiology and Imaging,
BIRDEM from 1st of July 2013 to 30th of June
2015.Elderly patients (>60 years) who were
referred for medical checkup and advised for MRI
of brain without manifestations of neurological
deficit were included in the study.
Inclusion criteria: Elderly subjects (>60 years)
referred for MRI of brain without anymanifestation
of neurological deficit were included in the study.
Exclusion Criteria: Uncooperative and
unconscious patient, patients with suspected stroke
(infarction/ haemorrhage) and Patients with
suspected intracranial neoplasm were excluded
from the study.
Mini Mental Status Examination:
The mini mental status examination (MMSE) is a
useful screening questionnaire to detect cognitive
impairment. A score of less than 24 out of 30
indicates cognitive impairment. It usually takes
around 5 minutes to administer and therefore can
be used routinely. It is an eleven question measure
that tests five areas of cognitive function:
orientation, registration, attention, recall and
language. The whole thing is depicted in a chart.
Scanning Technique
For the purpose of this study, MRI of brain was
performed on a Neusoft 0.35T scanner (Neusoft
Medical Systems Co. Limited, China).
Consent was taken from the patient and the
purpose of this research was explained to them.
Interpretation of MRI of Brain
Presence, severity and location of morphological
brain characteristics were rated according to the
protocol designed for the Rotterdam Scan Study.
WMLs were considered present in cases of
hyperintense lesions on both FLAIR and T2-
Weighted images but not hypointense on T1-
weighted images. When the largest diameter of
Correlation of Mental Status of Elderly Subjects With Cerebral White Matter T2 Naffisa Abedin et al
37
the WML was adjacent to the ventricle, it was
considered as periventricular, otherwise as
subcortical.
Periventricular WMLs were rated semi-quantitatively as:
• 0 (none)
• 1 (pencil thin lining)
• 2 (smooth halo), or
• 3(large confluent)
Three separate regions that considered were:
• Adjacent to frontal horns (frontal caps),
• Adjacent to the wall of the lateral ventricles(bands), and
• Adjacent to the occipital horns (occipital caps).
The overall degree of periventricular white matterlesions was calculated by adding up the scores forthe three separate categories (range: 0-9).
Statistical analysis of data
All the relevant collected data were compiled on amaster chart first. Then data was organized byusing scientific calculator and standard statisticalformulas. Percentage was calculated to find outthe proportion of the findings. Further statisticalanalyses of the results were done by computersoftware device as statistical packages for socialscience (SPSS). The results were presented astext, tables, figures, diagrams, etc. A value ofp<0.05 was considered statistically significant.
Variables were demonstrated as (Mean ± SD) forages & (Mean ± SEM) for the remaining allparameters. Pearson’s correlation was used forevaluation of the relationship among differentparameters for the validity of the study outcome.
Data Collection
After informing, all the necessary informationregarding the research study, data were collectedin a structured data collection sheet.
First the main researcher examined the MiniMental State Examination (MMSE) score of the
patient and also MRI of brain. It was then cross
examined by a senior radiologist.
Results:
A total of 80 consecutive subjects aged 61 to 90
years were selected in this study, out of which 31
were females and 49 were males.
Mental status was examined by mini mental status
examination (MMSE) protocol which was assigneda scoring system. A score of <24 was consideredabnormal (cognitive decline present).
All the subjects then underwent a non-contrastMRI of the brain for evaluation of location andextent of white matter hyperintensities in T2Wand FLAIR image sequences.
Among 80 total subjects, 36 of them had MMSE>/=24 (45%), out of which 12 were females and 24were males. Similarly, 44 of them had MMSE<24(55%), out of which 19 were females and 25 were
males (Table-I).
Table - I
Distribution of male and female subjects
according to MMSE score
MMSE Score Sex Total
F M
15-17 04 06 10
18-20 12 10 22
21-23 03 09 12
24-26 09 13 22
27-30 03 11 14
Total 31 49 80
Periventricular N=23 (28.8%)
Periventricular + Subcortical n=57(71.2%
Fig.- 1: Pie chart showing the distribution of
periventricular and periventricular + subcortical
white matter hyperintensities at MRI of brain.
Bangladesh Journal of Radiology and Imaging Vol. 23(1): January 2015
38
Table – II
Showing Frequency of periventricular score
along with their percentage
Frequency of periventricular score along with
their percentage
Score Frequency Percent
3 12 15
4 20 25
5 12 15.0
6 10 12.5
7 16 20
8 07 8.8
9 03 3.8
Total 80 100.0
Extent of periventricular white matter
hyperintensities evaluated by MRI of both male
and female subjects were correlated with their
MMSE scores.Among 12 subjects ( periventricular
score 3),10 had MMSE score>/=24 and 02 had
MMSE score<24.Out of 20 subjects(Periventricular
score 4),14 had MMSE >/=24,06 had MMSE<24.12
subjects(periventricular score 5),09 subjects had
MMSE>/=24 and 03 had MMSE<24.Another 10
with periventricular score of 6,03 had MMSE>/=24
and 07 had MMSE<24.However when the
periventricular score was>7,all the subjects had
MMSE<24.Score of mini mental status examination
(MMSE) of 80 subjects were correlated with the
extent of periventricular whiter matter
hyperintensity at MRI of brain. The value of Pear
son’s correlation coefficient was -0.78, meaning
there was a negative correlation between
periventricular white matter hyperintensity and
mini mental status examination. The test statistic’t’
test was significant (p<0.001). Thus there was a
significant negative correlation between the two
variables.
When mini mental status examination score wasseparately correlated with hyperintensities in the
frontal periventricular white matter (frontal cap),
we found a negative correlation between the two
variables.
When mini mental status examination score was
separately correlated with periventricular whitematter band opacities, a negative correlation
between the two variables was found.
When mini mental status examination score was
separately correlated with periventricular occipital
white matter opacities, a negative correlation
between the two variables was found. Pearson’scorrelation coefficient was -0.59 and the test
statistic ‘t’ test was significant at p<0.0001).
Score of mini mental status examination (MMSE)of 80 subjects were correlated with the largest sizeof subcortical lesion at MRI of brain. A positivecorrelation was found between these twoparameters.
The value of Pearson’s correlation coefficient was
0.018 and the test statistics ‘t’ test was not
significant (p=0.897).
Fig. – 2: (a) T2W and (b) FLAIR images (MMSE of this subject was 17. Periventricular white matter
hyperintensities are noted, rated as 3 each for frontal caps and occipital cap while 1 for bands. Total
score=7.)
Correlation of Mental Status of Elderly Subjects With Cerebral White Matter T2 Naffisa Abedin et al
39
Discussion:
This cross-sectional study was carried out with an
aim to establish whether any correlation exists
between white matter changes in brain of elderly
persons assessed by MRI with their mental status
assessed by mini mental status examination
(MMSE).
A total of 80 elderly consecutive subjects (>60
years) who were referred for MRI of brain without
manifestations of neurological deficit were
included, while uncooperative, unconscious
patients and patients with suspected stroke or
intracranial neoplasm were excluded from the
study. Among them, 31 were females and 49 were
males.
In this study, 80 patients were divided into three
age groups. The mean age was 68.59 ± 7.249 years.
Maximum number of cases was found in the 61-70
years age group. Similar study done by de leeuw
et al4 showed a mean age 72.4 year but they had a
significantly larger sample size of 1077 subjects.
Among 80 total subjects, 36 of them had MMSE >/=24 (45%).Among 31 females enrolled for the study,
61.30% had MMSE less than 24, while among 49
males,51.02% had MMSE less than 24.A study done
by F-E de Leeuw et al.4 has shown that for all age
categories and at every location, proportionally
more women than men had the most severe
periventricular white matter lesions, more
specially in the frontal region.
Periventricular white matter lesions were rated
semi quantitatively. The overall degree of
periventricular white matter lesions was calculated
by adding up scores for three separate categories
(range:0-9). It was observed that the highest
frequency was seen with the periventricular score
of 04(n=23).
When the score of mini mental status examination
(MMSE) of 80 subjects were correlated with the
extent of periventricular white matter
hyperintensity at MRI of brain, a significantnegative correlation was found between these twoparameters. The value of Pearson’s correlationcoefficient was -0.78 and the test statistic ‘t’ testwas significant at p<0.0001. A study done by GardeE. et al.7 showed that increase of white matterhyperintensity was significantly correlated with asimultaneous decline of cognitive function most
notably verbal function (r=-0.65; p<0.001). This
observation has also been supported by a study
done by Brickman et al.1 who studied in a total of
717 patients and found that increased white matter
hyperintensity volume was associated with poorer
cognition and higher cognitive and brain reserve
were associated with better cognition.
When MMSE score was separately correlated withhyperintensities in the frontal periventricularwhite matter (frontal cap), a significant negativecorrelation was found (r=-0.71; p<0.0001). Also,
when MMSE score was correlated with
periventricular white matter band opacities, a
significant negative correlation was observed (r=-
0.55; p<0.0001). Similarly, when MMSE score was
correlated with periventricular occipital white
matter hyperintensities (occipital cap), a significant
Fig.-3: (a) FLAIR and (b) T2W images. (MMSE score was 24. Both periventricular and subcortical white
matter hyperintensities are noted. Periventricular hyperintensities rated as 2 each for frontal caps, bands
and occipital cap. Total score=6)
Bangladesh Journal of Radiology and Imaging Vol. 23(1): January 2015
40
negative correlation was found between the two
(r=-0.52; p<0.0001). This suggests that there is a
negative correlation between MMSE score and
periventricular white matter hyperintensities
when assessed separately. Among the three,
frontal periventricular white matter showed
relatively more negative correlation than the other
two. de Groot et al.2 found out that when
periventricular white matter lesions were analyzed
for frontal, occipital and lateral regions separately,
more severe WMLs in all three periventricular
regions were related with poorer Cognitive index
scores and poorer memory scores (all p trend
<0.01).
However, when the score of mini mental status
examination (MMSE) of 80 subjects were correlated
with the largest size of subcortical lesion at MRI
of brain, a positive correlation was found between
these two parameters. The value of Pearson’s
correlation coefficient was 0.018 and it was not
significant (p=0.897). Van Harten B. et al.8 found
out that only periventricular white matter
hyperintensities was independently associated with
cognitive decline, more notably for executive
functions, mental and motor speed (p<0.05)
whereas subcortical lesions were not associated
with cognitive decline. Similarly, the current study
also showed that mental status was not affected
by subcortical lesions. de Groot et al.3 showed that
for subcortical WMLs, no relation was found
between subcortical WMLs and any of the three
cognitive compound scores.
Conclusion
As the findings of the present study are almost
identical as observed by many other investigators
in the past, it can be concluded that a statistically
significant negative correlation exists between
extent of periventricular white matter
hyperintensities at MRI of brain with cognitive
decline in elderly subjects. But no such correlation
exists between subcortical white matter
hyperintensities and mental status of elderly
subjects.
References:
1. Brickman AM, Siedlecki KL, Muraskin J,
Manly JJ, Luchsinger JA, Yeung LK, Brown
TR, et al. White matter hyperintensities and
cognition; testing the reserve hypotheses.
Neurobiology of aging 2011; 32(9):1588-1598.
2. de Groot JC, de Leeuw FE, Oudkerk M, van
Gijn J, Horman A, Breteler MM. Cerebral
white matter lesions and cognitive function.
the Rotterdam Scan Study. Annals of
neurology 2000;47 (2):145-151.
3. de Groot JC, De Leeuw FE, Oudkerk M, van
Ginj J, Hofman A, Breteler MM.
Periventricular cerebral white matter lesions
predict rate of cognitive decline. Annals of
neurology 2002;52,(3): 335-341.
4. de Leeuw FE, de Groot Jc, Achten E, Oudkerk
M, Ramos LMP, Heijiboer R, et al. Prevalence
of cerebral white matter lesions in elderly
people: a population based magnetic
resonance imaging study. The Rotterdam
Scan Study. Journal of neurology,
neurosurgery and psychiatry 2001; 70(1):9-14.
5. Rowland LP, Pedley TA, Merritt HH. Neuro-
psychologic evaluation, Merritt’s neurology.
12th ed. Philadelphia: Lippincott Williams &
Wilkins; 2010. P 213-221.
6. Koga H, Yuzuriha T, Yao H, Endo K, Hiejima
S, Takashima Y, et al. Quantitative MRI
findings and cognitive impairment among
community dwelling elderly subjects. Journal
of neurology, neurosurgery and psychiatry
2002;72(6): 737-741.
7. Garde E, Lykke Mortensen E, Rostrup E,
Paulson OB. Decline in intelligence is
associated with progression in white matter
hyperintensity volume. Journal of neurology,
neurosurgery and psychiirty 2005; 76(9):1289-
1291.
8. Van Harten B. Oosterman J, Muslimovic D,
et al., Cognitive impairment and MRI
correlates in the elderly patients with type 2
diabetes mellitus. Age and ageing 2007;
36(2):164-170.
Correlation of Mental Status of Elderly Subjects With Cerebral White Matter T2 Naffisa Abedin et al
41
REVIEW ARTICLE
Unilateral Pulmonary Hypoplasia - A Case Report
and Literature ReviewSHAH MUHAMMAD MUSTAQUIM BILLAH1, JAHIRUDDIN MOHAMMAD2, KONA GHOSH3,
HUSNE ARA4, FARHANA KAMAL KUMU5, REGINA BILQUISE TANIA5, MOLUA JAHAN5,
RUMANA PARVIN5
1.Associate Professor & Head, Department of Radiology & Imaging, Jalabad Ragib-Rabeya Medical college Hospital,Sylhet. 2. Professor, Department of Radiology & Imaging, Jalabad Ragib-Rabeya Medical college Hospital, Sylhet.3. Associate Professor, Department of Radiology & Imaging, Jalabad Ragib-Rabeya Medical college Hospital,Sylhet. 4. Associate Professor, Department of Radiology & Imaging, Dhaka Medical college Hospital, Dhaka.5.Radiologist, Department of Radiology & Imaging, Dhaka Medical college Hospital, Dhaka
Abstract:
A 37 days infant presented with fever & respiratory
distress since birth. Chest X-ray showed
homogenously opaque right hemithorax with
hyperlucency of left lung field & shifting of
mediastinum to right; initially diagnosed as agenesis
of right lung. After detailed evaluation including
Bronchoscopy and Computerised Tomographic (CT)
scan , a final diagnosis of unilateral pulmomanry
hypoplasia was made. This condition must be
suspected in differential diagnosis in a young person
presenting with features of lung collapse.
Key words:Pulmonary hypoplasia, Opaque
hemithorax.
Introduction:
Congenital malformations of the lung are rare andvary widely in their presentation and severity. Theirmanagement can be a challenge, since they areoften mis-diagnosed for the more common entitiesaffecting the lung, and a high index of suspicion isrequired to make an early diagnosis. Many patientswith congenital malformations present in adult lifewhen a clinical diagnosis becomes more difficult,consequently these patients are often mismanaged.We report the case of a young girl with unilateralpulmonary hypoplasia who was initially treated aspneumonic consolidation.
Case report:
A 37 days infant presented with cough for 20 days,irregular fever & respiratory distress since birth.Fever was high grade, intermittent in nature;highest recorded temperature- 103º F. She wasborn of a non-consanguineous marriage. Herperinatal history was uneventful and none of her
siblings had similar complaints. On examinationthe patient was febrile (temp. 102º F), apex beaton right 4th intercostal space, heart rate 144 bpm,decreased movement of right hemithorax,respiratory rate 36/min, breathsound was vesicular& diminished on right side, no added sound, liverwas palpable from left subcostal margin. Rest ofthe systems were within normal limits.
Routine haematological investigations revealed –C.R.P.-negative, Hb- 10 gm/dl, W.B.C.- T.C.-8000/mm3, D.C- N-56%, L-38.4%, Platelet-adequate.
Chest X-ray showed homogenously opaque righthemithorax with hyperlucency of left lung field &shifting of mediastinum to right. The CT scanrevealed complete absence of aerated lung tissueon right side with gross ipsilateral mediastinal shift,the right main bronchus was of smaller caliber thanthe left and ended abruptly just distal to the trachealbifurcation, the upper part of left lung was seenherniated to the opposite side due to compensatoryhypertrophy, the right pulmonary artery was alsomuch smaller as compared to the left side; theoverall radiographic features were compatible witha right-sided pulmonary hypoplasia.
Rigid bronchoscopy showed slit like right bronchial tree.Echocardiography showed dextrocardia. Abdominalultrasonography revealed no abnormality. She wasdiagnosed as a case of right-sided pulmonaryhypoplasia. In view of her symptoms and absenceof associated congenital anomalies, symptomatictreatment was given. The patient was dischargedafter explaining the nature of the illness to herparents. She has been on regular follow up for eightyears. Her radiological picture has not changed andshe has respiratory distress and underweight.
BANGLADESH JOURNAL OF RADIOLOGY AND IMAGING 2015; VOL. 23(1): 42-45
Discussion:
The fetal respiratory system begins to form post-conceptionally on day 22 as a ventral outpouching ofthe foregut endoderm below the pharynx. Thislaryngo-tracheal diverticulum becomes progressivelyseparated from the digestive tract, and the tracheabifurcates in 2 bronchial buds that penetrate theneighboring mesenchyma. Finally, subsequentramifications of bronchi and bronchioles form thepulmonary structures, which are covered by bloodvessels derived from the foregut mesoderm1.
Monaldi2 divided the mal-development of lung infour groups. Group I:No bifurcation of trachea;
Group II: Only rudimentary main bronchus; GroupIII: Incomplete development after division of mainbronchus; and Group IV: Incomplete developmentof subsegmental bronchi and small segment of thecorresponding lobe. The present case belongs tothe third group of Monaldiclassification.
According to Boyden3 there are three degrees of
mal-development: (i) agenesis, in which there is
complete absence of lung tissue, (ii) aplasia, in
Fig.-1: Chest radiograph on 29/
7/2009 at the age of 29 days,
showing opaque right hemi-
thorax with mediastinal shifting.
Fig. 2: Chest X-ray AP & Right Lateral View taken on 11/01/2010,
showing-opaque right hemi-thorax, mediastinal shifting,
hyperinflation with herniation of left lung and hemi-vertebrae at D8& D9.
Fig 3: CT scan of Chest showing right lung consolidation with
airbronchogram in lower lobe and mediastinal shifting.Fig 4: Chest radiograph taken on 05/
12/2016 showing showing-opaque
right hemithorax, mediastinal
shifting, hyperinflation with
herniation of left lung and hemi-
vertebrae at D8 & D9.
Unilateral Pulmonary Hypoplasia - A Case Report and Literature Review Shah Muhammad Mustaquim Billah et al
43
which rudimentary bronchus is present but no lung
tissue is present, and (iii) hypoplasia, in which all
the normal pulmonary tissues are present but are
under-developed.
In pulmonary hypoplasia signs are seen beyond
the bronchial trunk. Hypoplasia may be either
general, involving the whole lung, or partial.
Depending on the stage of fetal development in
which hypoplasia occurs, it may be lobular,
segmental, subsegmental, or bronchial1.
Hypoplasia of the lung may be regarded as primary
(idiopathic) or secondary. The incidence of
secondary form is difficult to determine; however,
because of its association with a variety of other
abnormalities and the difficulty of pathologic
diagnosis in some cases, it is likely to be more
common than generally recognized. The incidence
of primary hypoplasia has been estimated to be 1
to 2 per 12,000 births. Several mechanisms have
been implicated in secondary pulmonary hypoplasia
including decreased hemithoracic volume-
congenital diaphragmatic hernia, extralobar
sequestration, agenesis of the diaphragm,
mediastinal mass, decreased pulmonary vascular
perfusion, decreased fetal respiratory movement
and decreased lung fluid, skeletal dysplasia those
causing narrow fetal thorax, large intra-abdominal
mass compressing the thorax1, 2.
Clinically, infants with unilateral lobar pulmonary
hypoplasia may have variable presentations
depending on the extent of lung involvement and
co-morbidities. Some infants present with severerespiratory distress in the first few hours of lifewhereas some may be completely asymptomatic.Some patients may present months to years laterwith repeated pulmonary infections and wheezing4.
Physical examination characteristically revealsasymmetry of two sides of thorax, reduction inrespiratory movements and absence of air entryin the affected side. This may be diagnosed
incidentally during childhood when complicated by
pulmonary infection. Still however there are no
clear clinical diagnostic criteria to facilitate the
identification and management of lung hypoplasia5.
Radiographic findings in cases of hypoplasia are
similar and characterised principally by almost
total absence of aerated lung in one hemithorax.
The markedly reduced volume is indicated by
approximation of ribs, elevation of ipsilateral
diaphragm, and shift of the mediastinum. In most
cases the contralateral lung is greatly over inflated
and displaced along with anterior mediastinum into
the involved hemithorax; this displacement of air
containing lung to the side of involved lung may
lead to some confusion in diagnosis. CT scan may
be required to establish the degree of under
development and to differentiate hypoplasia from
other conditions that may closely mimic it
radiographically2.
The differential diagnosis of respiratory distress
in the newborn associated with marked
opacification of one side of the thorax on radiograph
includes atelectasis, congenital diaphragmatic
hernia (CDH), congenital cystic adenomatoi-
dalformation (CCAM), pulmonary sequestration,
chylothorax, pulmonary hypoplasia, bronchogenic
cyst, and a chest tumor (e.g., neuroblastoma,
teratoma, fibrosarcoma). In a right-sided CDH,
there may be opacification of the right hemithorax
if the liver is occupying that space. A left-sided
CDH will have air-filled loops of bowel in the chest
except possibly in a chest radiograph taken shortly
after birth or following bowel decompression.
CCAM will usually appear as a cystic mass rather
than a homogenous opacification. A chylothorax
that presents in the first few days of life may be
due to a congenital malformation of the lymphatic
system or traumatic injury of the thoracic duct atdelivery. Obstruction of the bronchus withresultant opacification of the hemithorax may occurwith a bronchogenic cyst or a vascular sling.Neonatal chest tumors are very rare and may
present as a focal abnormality on CXR6.
Nowotnyet al.7 recommended pulmonary function
tests for infants with pulmonary hypoplasia. If
PFTs reveal airflow obstruction and elevated
resistance, then flexible bronchoscopy is
recommended. In the present case, the initial
PFTs were not done. This may reflect the
inaccuracy of the test or the possibility that the
airway obstruction actually worsened during the
first months of life, which is frequently the clinical
course for laryngomalacia and tracheomalacia. Wu
Bangladesh Journal of Radiology and Imaging Vol. 23(1): January 2015
44
et al.8 described a case of unilateral lung hypoplasia
diagnosed by three-dimensional reconstruction of
helical chest CT. Argent and Cremin9 used
contrast-medium-enhanced CT to elucidate the
anatomy of two patients with right lung agenesis.
Becmeuret al.10 were only able to diagnose an
accessory diaphragm with the use of an MRI scan.
It was not clear on CT scan whether the finding
represented an accessory diaphragm or a band of
atelectasis.
A number of associated anomalies have been
described in patients with pulmonary hypoplasia, but
none has been specifically associated with patients
with lobar hypoplasia. Nakamura et al.11 in a large
series of autopsy cases revealed five statistically
significant risk factors associated with pulmonary
hypoplasia: (1) hydropsfetalis; (2) renal anomalies;
(3) diaphragmatic hernia; (4) skeletal anomalies; (5)
oligohydramnios and polyhydramnios.
The natural history in the case reported illustrated
the importance of close follow-up for neonates with
unilateral lobar pulmonary hypoplasia. Although
mildly symptomatic or asymptomatic during the
newborn period, they may develop obstructive
pulmonary disease associated with
tracheobronchomalacia and reactive airway
disease. It could be argued that all neonates with
pulmonary hypoplasia should have pulmonary
function testing. If PFTs are abnormal or there
are clinical signs of airway disease, flexible
bronchoscopy should be performed to assess for
tracheobronchial abnormalities. All infants with
suspected pulmonary hypoplasia should have an
echocardiogram to assess for congenital cardiac
defects as well as to assess pulmonary venous
drainage. Chromosomes should be sent if there
are multiple anomalies. The long-term prognosis
is directly related to the degree of pulmonary
hypoplasia and presence of comorbidities
References:
1. Gabarre JA, Izquierdo AG, Ponferrada MR,
Gallardo CO, Agueda JMP, Perez PF. Isolated
Unilateral Pulmonary Agenesis. J
Ultrasound Med 2005; 24:865-8.
2. Kant S. Unilateral pulmonary hypoplasia – a
case report. Lung India 2007; 24:69-71.
3. Boyden EA. Developmental anomalies of the
lungs. AM J Surg. 1955; 89-89.
4. Thomas RJ, Lathif HC, Sen S, Zachariah N,
Chako J. Varied presentations of unilateral
lung hypoplasia and agenesis: a report of four
cases. Pediatr Surg Int 1998;14:94–5.
5. Rutledge JC, Jensen P: Acinar dysplasia: A
new form of pulmonary mal-development.
Hum Pathol. 1986;17:1290.
6. Abrams ME, Ackerman VL, Engle WA.
Primary Unilateral Pulmonary Hypoplasia:
Neonate through Early Childhood-case
report, radiographic diagnosis and review of
the literature. Journal of Perinatology 2004;
24:667-70.
7. Nowotny T, Ahrens B, Bittigau K, et al. Right-
sided pulmonary aplasia: longitudinal lung
function studies in two cases and comparison
to results from healthy term neonates.
Pediatr Pulmonol 1998; 26:138–44.
8. Wu C, Chen M, Shih S, Huang F, Hou S. Case
report: Agenesis of the right lung diagnoses
by three-dimensional reconstruction of helical
chest CT. Br J Radiol 1996; 69:1052–4.
9. Argent A, Cremin B. Computed tomography
in agenesis of the lung in infants. Br J Radiol
1992; 65:221–4.
10. Becmeur F, Horta P, Donato L, Savage P.
Accessory diaphragm review of 31 cases in the
literature. Eur J Pediatr Surg 1995; 5:43–7.
11. Nakamura Y, Harada K, Yamamoto I, et al.
Human pulmonary hypoplasia: statistical,
morphological, morphometric, and biochemi-
cal study. Arch Pathol Lab Med 1992; 116:
635–42.
Unilateral Pulmonary Hypoplasia - A Case Report and Literature Review Shah Muhammad Mustaquim Billah et al
45
Pancreatitis with Unusual Sequelae: A Case ReportMAHFUZ ARA FERDOUSI1, FARZANA SHEGUFTA2, ISHTIAQUE MOHAMMAD BEHNOM3,
MOUSUMI MONDAL4, M IRFANUL ALAM5
1. Associate Professor, Department of Radiology and Imaging, BIRDEM General Hospital, Dhaka. 2. Assistant
Professor,Department of Radiology and Imaging , BIRDEM General Hospital, Dhaka. 3. MD Resident, Department
of Radiology and Imaging, BIRDEM General Hospital, Dhaka. 4. Resident, Department of Radiology and Imaging,
BIRDEM General Hospital, Dhaka. 5. Honorary Medical Officer, Department of Radiology and Imaging, BIRDEM
General Hospital, Dhaka.
Abstract
Acute pancreatitis is an important cause of acute
abdominal pain. Imaging plays the central role in
the management of selected cases of acute
pancreatitis, complementing laboratory
investigations such as serum amylase and lipase
levels that have relatively high sensitivity and
specificity. In addition to clinical signs and
laboratory investigations, imaging helps in
confirming the clinical diagnosis when or if there
is any uncertainty. Imaging also helps in
elucidation of the cause and grading the extent &
severity of acute pancreatitis. Besides all of the
mentioned advantages Imaging aids in the early
detection of complications too.
Key Words: Pancreatitis, Colitis, Ultrasonography,
CT scan.
Introduction
The multisystem involvement in acute pancreatitis
is a reflection of the pancreatic gland’s capacity to
produce a number of potent vasoactive peptides,
hormones, and enzymes. Proteolytic enzymes,
lipase, kinins, and other active peptides liberated
from the inflamed pancreas convert inflammation
of the pancreas, a single-organ disease of the retro-peritoneum, to a multisystem disease1. Theinflammatory process associated with extravasated
pancreatic enzymes may disseminate along the root
of the small bowel mesentery, either for a portion
or for its entire length. Acute pancreatitis may
clinically mimic an acute appendicitis with
peritoneal signs localized predominantly in the
right lower quadrant. This is a reflection of the
process spreading along the length of the root of
the small bowel mesentery to result in
inflammatory changes of distal ileal loops or the
caecum. 2
Case Report
A 24 year old male presented with the complaints
of epigastric pain for 8 days which was gradual on
onset, severe in intensity, non-radiating in nature.
The pain was associated with vomiting but not with
fever. Patient gave past history of similar sort of
pain two times. He was non-alcoholic, non-smoker,
normotensive & non-diabetic. Physical examination
showed tenderness in epigastric & right iliac region
with muscle guarding. Routine investigation of
blood revealed raised serum lipase. USG was done
which showed hepatomegaly with Grade–II fatty
change with mildly swollen pancreas (figure-1). CT
scan of W/A was also performed revealing
heterogeneously enhancing mass lesion with
marked fat stranding in right side of abdomen,
abutting ascending colon causing intestinal
obstruction (figure-3). The lesion was of soft tissue
density in non-contrast films (figure-2). Possibility
of inflammatory mass was more than neoplastic
lesion. A follow up USG was evidenced by the
constant observation regarding the mass which
measured about 87.2 mm x 35.7 mm (figure-4). On
the same day serum lipase level was repeated and
it raised to 723 U/L which was significantly above
normal level. Later the patient underwent a
colonoscopy. During colonoscopy it was found that
the mucosa of the caecum is hyperemic &
edematous (figure-5). Biopsy was also taken.
Histopathology of the biopsied caecal part
suggested that there is active colitis in the caecum,
CASE REPORTS
BANGLADESH JOURNAL OF RADIOLOGY AND IMAGING 2015; VOL. 23(1): 46-48
46
no malignancy was reported. In the colonoscopy
report it was also commented that the mucosa,
vascular pattern & lumen throughout the colon
including the rectum appeared normal.
From above clinical scenario & investigations this
case was diagnosed as a case of active colitis with
an inflammatory caecal mass following acute non
necrotizing pancreatitis.
Fig.-1: Ultrasonography showing hepatomegaly
with grade-II fatty change & mildly swollen
pancreas
Fig.-2: CT scan of whole abdomen showing soft
tissue density lesion in right side of abdomen at
non-contrast axial scan
Fig.-3: CT scan of whole abdomen revealing
heterogeneously enhancing mass lesion with marked
fat stranding in right side of abdomen, abutting
ascending colon causing intestinal obstruction at
post contrast axial and coronal section
Fig.-4: Follow up Ultrasonography showing the
said mass in right Iliac Fossa which measures about
87.2 mm X 35.7 mm
Fig.-5: Colonoscopy revealing hyperemic&
oedematous mucosa of the caecum.
Pancreatitis with Unusual Sequelae: A Case Report Mahfuz Ara Ferdousi et al
47
Discussion
Acute inflammation of the pancreas may be
classified into various groups: Acute edematous
pancreatitis which is the most common form where
there is localized or diffuse swelling of the organ.
Other forms include Acute hemorrhagic
pancreatitis, Acute gangrenous pancreatitis which
is very rare. Lastly acute suppurative pancreatitis
which is secondary to superimposed infection may
range from a localized pancreatic abscess to diffuse
involvement, perhaps as a gas-producing process.
Localized changes on characteristic portions of the
small intestine and colon are produced by the
extravasated enzymes of pancreatitis, which follow
definite anatomic planes.2 The lesions range from
transient spasm to ischemic atrophy and the
development of obstructive strictures as well as
remote exudative abscesses. Extension of the
effects of pancreatitis may occur through the loose
retroperitoneal tissue planes of the anterior
pararenal spaces. Notably, however, the
mesenteric pathways most often involved and that
direct the spread of pancreatic enzymes to remote
sites in the intestinal tract are the transverse
mesocolon and the small bowel mesentery. These
observations have been confirmed by computed
tomography.3 Virtually all of the pancreas is an
extraperitoneal organ. However, a
nonperitonealized bare area results from the
reflections of the posterior parietal peritoneum to
form the two leaves of the transverse mesocolon.4
This extends across the lower border of the organ
anteriorly. On the right, the transverse mesocolon
begins at the point where the anterior hepatic
flexure of the colon immediately crosses ventral
to the second portion of the duodenum. The bare
area then extends as a broad strip across the
infraampullary portion of the descending
duodenum and continues across the head, body,
and tail of the pancreas. Of further clinical
significance is the fact that the root of the small
bowel mesentery, at its origin near the inferior
portion of the pancreas, is anatomically continuous
with that of the transverse mesocolon. At this
point, it is in relationship to the mid-portion of the
transverse duodenum. It then extends obliquely
toward the right lower quadrant to insert, most
often, at the cecocolic junction. Thus, anatomic
continuity is established along the root of the
mesentery from the pancreas to the third portion
of the duodenum, jejunal loops, ileal loops, and
cecum. In this way, mesenteric planes are provided
for the direct spread of extravasated pancreatic
enzymes.5
Conclusion
Imaging plays an important role in the
management of the patient with acute pancreatitis.
In this particular case the dilemma was whether
the mentioned mass lesion was due to inflammatory
cause or whether it was a neoplastic lesion. In such
cases CT scan with contrast examination can be a
valuable modality of choice in helping making a
correct diagnosis.
References
1. Millar FH, Keppke AL, Balthazar EJ.
Pancreatitis. In: Gore GM, Levine MS, eds.
Textbook of gastrointestinal radiology, 3rd ed.
Philadelphia, PA: Elsevier, 2008:1885–1915
2. Meyers MA, Evans JA: Effects of pancreatitis
on the small bowel and colon: Spread along
mesenteric planes. AJR, 1973; 119:151–165.
3. Meyers MA, Oliphant M, Berne AS et al: The
peritoneal ligaments and mesenteries:
Pathways of intra-abdominal spread of
disease. Annual oration, Radiology, 1987; 163:
593–604.
4. Meyers MA, Whalen JP: Roentgen
significance of duodenocolic relationships:
Anatomic approach. AJR Rad Ther Nucl Med
1973; 117:263–274.
5. Meyers MA, Dynamic Radiology of the
Abdomen: Intestinal Effects of Pancreatitis:
Spread Along Mesenteric Planes, Springer
Science & Business Media, New York 1988;
341-363.
Bangladesh Journal of Radiology and Imaging Vol. 23(1): January 2015
48
Bilateral Thalamic Hyperdensities – A Diagnostic
Feature of Sandhoff’s DiseaseSYEEDA SHOWKAT1, ABISHEK POKHREL2, BISHWAJIT BHOWMIK3, SHAHRYAR NABI4,
SHAIKH MD NURUZZAMAN5, ANINDITA DATTA6
1.Associate Professor. 2. Phase-B Resident and 3. Associate Professor, Department of Radiology and Imaging,
BSMMU (Bangabandhu Sheikh Mujib Medical University), Dhaka. 4. Associate professor, Department of Radiology
and Imaging, Dhaka Medical College, Dhaka. 5. Consultant Radiologist, Green Life Hospital, Dhaka.6. Assistant
Professor, Department of Radiology and Imaging, BSMMU, Dhaka.
Abstract:
Sandhoff disease is a rare but severe autosomal
recessive disease caused by deficiency of lysosomal
enzyme hydrolase β-hexosaminidase A and β-
hexosaminidase B. Here we present a case of 14
months old baby admitted with complaints of
headache and blurring of vision.CT scan of brain
showed bilateral symmetrical hyperdensities in both
thalamic regions.Enzymatic essays showed
deficiency of both hexosaminidase A and
hexosaminidase B confirming the diagnosis of
Sandhoff’s disease.
Keywords: Autosomal recessive disease, Computed
Tomography, Thalamic hyperdensity
Introduction:
Sandhoff disease is a rare type of autosomal
recessive disorder caused by deficiency of both
hexosaminidases A and B which results in the
accumulation of toxic metabolites GM2 in the
brain and visceral organs.Bilateral involvement
of the thalamus had long been touted to be
diagnostic of Sandhoff’s disease and areas such
as cerebellum,white matter and basal ganglia may
also be found to be involved1.Typical presentation
with involvement of the thalamus has been
presented in this article.
Observation:
A 14 months old baby born by normal vaginal
delivery having uncomplicated post-natal
events had been brought to the Neurology out-
patient department with complaints of
headache and blurring of vision. No such
abnormalities were found in any of the first
degree relatives.
According to the baby’s parents clinical symptoms
came into notice at the age of 9 months when the
baby was unable to sit and turn side.Later on the
baby could not follow objects with eyes and had
diminished visual attention.Neurological
examination revealed hypotonia and diminished
response to light. Ophthalmologic funduscopic
examination revealed cherry red spot without any
evidence of optic atrophy. Computed Tomography
(CT) of brain without intravenous contrast was
performed which showed bilateral symmetrical
hyperdensities in the thalamus.
Fig.-1: Cherry red spot in fundoscopic examination
BANGLADESH JOURNAL OF RADIOLOGY AND IMAGING 2015; VOL. 23(1): 49-50
MRI of brain done immediately revealed symmetrical
T1WI hyperintensity and T2WI hypointensity in thethalamic regions though the scans could not bepresented here. Patient’s clinical history and CTfindings suggested GM2 gangliosidosis(Sandhoffdisease). Enzymatic assays were later performedwhich showed deficiencies of both hexosaminidase Aand hexosaminidase B, further narrowing ourdiagnosis to Sandhoff’s disease.
Discussion:Sandhoff disease is a rare autosomal recessiveinherited lysosomal disorder which results due tothe mutation in the HEXB gene. There are threeknown forms of the disease: Classic infantile,juvenile and adult late onset form. Classic infantileform presents anywhere from 2 months to 9months of age. It is the most common and severeof the three types where death generally resultsby the age of 3 years. They are symptomless untilthe age of 3 months after which delay indevelopmental milestones and muscle weaknessare seen. Affected infant loses motor functions suchas turning over, sitting over and crawling. Lateron the baby develops seizures, vision and hearingloss,paralysis and dementia2. Cherry red spot maybe found in funduscopic examination3.
Organomegaly and bone abnormalities are alsofrequently associated. Juvenile (3-10years) and lateadult onset form of the disease are associated withless severe symptoms. Juvenile and adult onsetforms of the disease are very rare too1. Treatmentoptions for the disease have not been fullyestablished until now.
Many earlier reports showed bilateral earlythalamic involvement to be an early sign in the CTscan of brain of patients with Sandhoff disease whichmay be due to loss of axons and myelin in the centralcortical neurons, gliosis and intralysosomal storagein addition to calcium accumulation.
Magnetic resonance imaging in such patientgenerally shows bilateral symmetricalhypointensity in thalamus, hypointensity in thecerebral white matter in T2WI and hyperintensityin T1WI in the thalamus.
Diagnosis is usually confirmed by enzymaticdeficiency of both hydrolase β−hexosaminidase Aand B4,5.To summarize Sandhoff disease is a raredisease entity of lysosomal storage disease.Bilateral thalamic hyperdensity along with cherryred spot in funduscopic examination is very muchsuggestive of Sandhoff disease in a patientsuspected for neurodegenerative disorder whichcan further be confirmed by enzymatic assays.
References1. Saouab R, Mahi M, Abilkacem R, et al. A Case
Report of Sandhoff Disease. ClinicalNeuroradiology. 2011;21(2):83-85. doi:10.1007/s00062-010-0035-4.
2. Autti T, Joensuu R, Aberg L. Decreased T2signal in the thalami may be a sign oflysosomal storage disease. Neuroradiology.
2007;49(7):571–8. doi: 10.1007/s00234-007-0220-6.
3. Yun Y, Lee S. A case report of Sandhoffdisease. Korean J Ophthalmol 2005;19:68–72
4. Hendriksz CJ, Corry PC, Wraith JE, BesleyGTN, Cooper A, Ferrie CD. Juvenile Sandhoffdisease—nine new cases and a review of theliterature. J Inherit Metab Dis. 2004; 27:241–9. doi: 10.1023/B:BOLI.0000028777.38551.5a.
5. Sandhoff K, Conzelmann E, Neufeld EF et al.The GM2 gangliosidosis. In: Scriver CV,Beaudet AL, Sly WS, Valle D, eds. TheMetabolic Basis of Inherited Disease. New
York: McGraw-Hill, 1989;1807-39.
Fig: Non contrast CT scan of brain showing
bilateral symmetrical hyperdensities in the region
of thalamus. No changes can be seen in the caudate
nucleus, globus pallidus and putamen.
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