Vol. 23, No. 1, January, 2015

(Published in June 2018)

BANGLADESH JOURNAL OF

RADIOLOGY AND IMAGING

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

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

Phone : 8613189, 9126995E-mail: info@bsribd.org Website: www.bsribd.org

EDITORIAL BOARD

Editor in Chief : 

Prof Abu Saleh Mohiuddin

Co-Editors:

Dr Shamim Ahmed

Prof Shibendu Mojumder

Col Zoherul Islam

Executive Editor:

Prof Md Mizanur Rahman

Executive Members:

Prof Md Enayet Karim

Prof Mahfuzur Rahman

Prof Farid Ahmed

Dr Delwar Hossain

Dr Mobarak Ali

Dr Sarwar Ramiz

Dr Syed Maksumul Haque

Dr Nilkantha Paul

Dr Mahmud Uz Jahan

EXECUTIVE COMMITTEE

PresidentProf Md Enayet Karim

Vice - PresidentProf Md Mizanur RahmanProf Shibendu Mojumder

Prof Sarwar Ramiz

Secretary GeneralDr Shahryar Nabi (Shakil)

TreasurerDr Md Shahidul Islam

Joint SecretaryDr Md Khalilur Rahman

Organizing SecretaryProf Md Rued Hossain

Office SecretaryDr Md Anisur Rahman Khan

Scientific SecretaryDr Bishwajit Bhowmick

Secretary for International AffairsProf Shahara Haque Zerin

Entertainment SecretaryDr Mahfuz Ara Ferdousi

MembersDr Shamim Ahmed

Dr Mahmood-Uz-JahanDr Fatema Doza

Dr Sushanta Kumar SarkerDr Bidoura TanimDr Asish Sarkar

Dr Dost Mohammad Lutfur RahmanDr SM Mustaquim Billah

Dr Farzana AlamProf Abu Saleh Mohiuddin

(Dhaka Division)Prof Anisul Mowla

(Chittagong Division)Dr Md Ashikur Rahman Mazumder

(Sylhet Division)Dr Md Hafizur Rahman

(Rajshahi Division)Dr Syed Maksumul Haq

(Barisal Division)Prof Shibesh Sarker(Rangpur (Division)

Dr Md Borhanuddin Ahmed(Khulna Division)

Dr Md Motiur Rahman(Mymensingh Division)

BANGLADESH SOCIETY OF

RADIOLOGY AND IMAGING

Bangladesh Journal of Radiology and Imaging a

biannual (January and July) journal, is the official

Journal of Bangladesh Society of Radiology and

Imaging.

Each issue will include original articles, review

articles, case reports and any other articles of

interest in Radiology and Imaging.

Manuscripts must be in English and should be

submitted to the Editor.

The manuscript should be in accordance with

the modified Vancouver (Ref. Bangladesh J of

Radiol 1993; (Vol. 1(1): 27-34 and be submitted in

two copies with two sets of illustrations.

Manuscripts should be accompanied by a

covering letter from the author who will be

BANGLADESH JOURNAL OF

RADIOLOGY AND IMAGING

Prof Nazrul Islam

Prof Hashem Ali

Prof Rezaul Mostofa

Prof ASQM Sadeque

Prof MA Bashar

Prof MI Mondol

Prof (Big Gen Rtd) Chowdhury  Abdul Gaffar

Prof Abdul Matin Khan

Prof Syed Abdul Matin

Prof Akhter Uddin Ahmed

Prof MA Quddus

Prof M Mahabubur Rahman

Prof Nasiruddin Miah

Prof (Big Gen Rtd) Jahangir Alam

Prof (Big Gen Rtd) Zuberul Islam

Prof Shafiqur Rahman

ADVISORY BOARD

Information for Contributors

responsible for correspondence regarding

manuscripts.

Papers will be accepted for publication provided

they are submitted solely with Bangladesh

Journal of Radiology and Imaging and are

subject to review and editorial decisions.

Statement and opinion expressed in papers are

those of author(s) and the editor(s) or publisher

bears no responsibility of such matter.

All decisions to accept, revise or refer a paper

will be made by the editorial board.

The paper which will not be accepted for

publication will not be returned back to the

author. No reprint will be provided.

INSTRUCTION TO AUTHORS

Authors are requested to follow Vancouver’s

style (N Engl J Med 1997; 336: 309-15) of writing

as outlined below, while submitting articles for

publication in BSRI Journal.

Preparation of manuscript : Typed

manuscript on white bond paper in quadruplicate

with margins of 2.5 cm is to be submitted.

Double spacing should be used throughout.

Pages are to be numbered consecutively,

beginning with the title page in the right upper

corner of each page.

Title page : The title page should contain the

title of the article, rank, name of authors with

academic qualification, word count of text and

abstract. It should also contain the name and

address of the author with whom

correspondence is to be made. The full name with

serial order of the authors written in write corner

as superscript. e.g., Calvin a Shadaw1, Mohammad

Selim Newas2 will be the format of placing the

name of the authors below be title.

Abstract : The abstract should be unstructured

and should state the purpose of the study orinvestigation, basic procedure, main findings and

the principal conclusion. It should be limited to

300 words for a review article. For original and

leading article, it should be less than 250 words.

For case report and short communication it

should not exceed 150 words.

Text : The text of the article should be divided

into sections with the following heading;

introduction, materials and methods, results,

discussion and conclusion.

Size of the article / Text : The size of review

article should be less than 3,000 wordsexcluding the abstracts, tables, illustrations,references and acknowledgment. For originalarticle or leading article it should be within

2,000 words. For case report the upper limit

should be 1000 words. For short communication

it should not exceed 600 words.

Tables and Illustrations : Tables and

illustrations should be self-explanatory and

supplementary but not duplication of the contents

of the text. Each table / illustration is to be typed

on a separate sheet, numbered in Roman

numeric and attached at the end of the test.

Tables should not have more than 3 horizontal

lines and no vertical lines. Photographs should

be clear, glossy and uncounted, diagrams and

graphs are to be in Indian ink. The number should

not exceed 10 for review article, 06 for original

article and 03 for a case report.

Acknowledgement : Only those persons who

have made substantial contributions to the article

should be acknowledged.

Reference: References are to be numbered

consecutively in the order in which they appear in

the text. Number of references for review article

should be less than 50 and for original article less

than 25. For case report and short communication

it should be less than 10. The forms of the

references should be as per examples below :

References from Journal : References should

be written according to the following sequence e.g.

authors (s) name, subject, name of Journal with

year of publication, volume number, page ‘

number. If there are six authors or less, names of

all the authors should be written. When there are

seven authors or more the first three names will

be listed and then word “et al” to be added. `

Example : Calne L, Swells J D, Somford RD, et al.

Further observation on renal transplantation in

man from cadaveric donors. BMJ 1996; 218: 1345-

1351.

References from books and monograph : In

case of personal authors(s) reference should be

written in the following sequence : author(s) name,

name of the books, number of edition, place by

publication, name of the publisher, year of

publication, pages, Example : Rhoder AJ. Text

Book of Virology. 5th ed. Balgimpore : Wilkins;

1968. P 469-465. In case of reference from books

edited by one and chapter written by some one;

the reference should be written in the following

sequence : name of author(s) name of chapter, name

of editor, name of books, place of publication, name

of publisher, year of publication, pages.

Examination : Insel PA. Analgesics antipyretics,

and anti-inflammatory agents. In: Gilman AG, Rall

TW. Nies AS, Tailor P, Editors, The

Pharmacological Basis of Therapeutic Singapore :

Pergamon Press; 199. p. 638-661.

Reference from dissertation or thesis : The

reference should be made in the following

sequence : name of author(s), subject, place of

publication, name of institute, year of study,

pages, Example :Tableb NA Bacteriological study

of diarrhoea in Bangladesh Thesis). Dhaka,

IPGM&R 1990. 65-90.

Reference of articles of magazines : The

reference should be made in the following

sequence : name of author(s), name of the

subject, name of the magazine, year and date,

pages. Example : Touche B. Annals of Medicine :

The santa claus culture. The new York 1991;

Sep. 4: 66-81.

Number of Authors : the number of authors

should be limited to 04, 05, and 08 for case

report, review article and original articles

respectively.

Check List : The authors should deposit the

following documents to the editorial board.

a. Letter of submission / forwarding letter.

b. A certificate stating that the contents of the

articles has not been published in any journal

and it has not been submitted to any otherjournal for publication.

c. A certificate from the head of the institutionwhere the original work has been done.

d. A specified certificate given by HigherHeadquarters.

e. Title - 05 copies

f. Abstract - 05 copies

g. Text of article - 05 copies

h. Table and illustration duly numbered

i. References

j. Compact Disc (CD) / Pendrive

k. Bio-data of principal authors.

Misc :

a. Preferably from one author there should not bemore than two case reports and one reviewarticle in a single issue of journal

b. Corresponding author’s & other authors ‘ nameand address should be printed in left lower cornerof the first page of the article.

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.

References

1. Fardon DF, Milette PC. Nomenclature and

classification of lumbar disc pathology:

Recommendations of the combined task forces

of North American Spine Society, American

Society of Spine Radiology, American Society

of Neuroradiology. The Spine Journal.2014;

26(5): 2525-5.

2. Williams NS, Bulstrode CJK, O’Connell PR.

Baily and Love’s Short Practice of Surgery.

25th ed. Hodder Arrold, London: 2008.

3. Pate D. Clinical significance of MRI findings

in the lumbar spine. Dynamic Chiro practice.

2013. 3(16).

4. Hagga JR, Dogra VS, Frosting M, Glikeson

RC, Ha HK, Sundaram M. CT and MR

imaging of the whole body. 5th ed. USA:

Mosby; 2009.

5. Osborn AG. Diagnostic Neuroradiology. St.

Luice (Missouri); Mosby USA: 1994.

6. Canale ST, Daugherty K, Jones L. Campbell’s

Operative Orthopaedics.10th ed. London:

Mosby; 2003.

7. Janardhana AP, Rajagopal Rao S, Kamath A.

Correlation between clinical features and

magnetic resonance imaging findings in

lumbar disc prolapse. Indian J Orthop. 2010

Jul-Sep; 44(3): 263-69.

8. Weiner BK, Patel R. Accuracy of MRI in the

detection of Lumbar Disc Containment.

Journal of Orthopaedic Surgery and research.

2008 Dec; 3(1): 46.

9. Van Rijn JC, Klemetso N, Reitsma JB, Majoie

PM, Hulsmans FJ, Peul WC. Observer

variation in MRI Evaluation of Patients

Suspected of Lumbar Disc Herniation.

American Journal of Radiology. 2005.184

(1):299-303.

10. Baldwin NG. Lumbar Disc Disease: The

Natural History. Neurosurg FOCUS.

2002.13(2):E2.

11. Kamal F, Quddus MA, Hossain A, Rahman

MM, Sarkar RN, Nabi S, Ahmed S,

Chowdhury N, Rahman K. Role of magnetic

resonance imaging (MRI) in the pre-operative

diagnosis of lumbar disc herniation. J Dhaka

Med Coll. 2009; 18(1):8-14.

Bangladesh Journal of Radiology and Imaging Vol. 23(1): January 2015

6

12. Roy SK. Treatment of Prolapsed Lumbar

Intervertebral Disc by minimally invasiveopen Lumbar discectomy. MS (ORTHO)Thesis, Bangabandhu Sheikh Mujib MedicalUniversity.2005.

13. Hossain MI. Role of Evaluation of low backpain(A study of 100 cases). FCPSDissertation, Bangabandhu Sheikh MujibMedical University. 2003.

14. Modic MT, Masary KT, Boumphery F,

Goorastic M, Bell G. Lumbar herniated disk

disease and canal stenosis: prospective

evaluation by surface coil MR, CT and

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.

Bangladesh Journal of Radiology and Imaging Vol. 23(1): January 2015

50