 Welcome to Indian Radiologist. Today I will be taking you on a tour of all the activities and programs that are scheduled for this year as well as for early Jan next year. We begin the Indian Radiologist section with the Journal Club. Now the Journal Club is a unique program that has been crafted out and created by Dr. Mitusha Verma as well as Dr. Gauri Aguja. In this program what we intend to do on the third Sunday of each month is that we take you through interesting articles that are coming about in the world of radiology. We will discuss them, we will dissect them and also look at what options the Journal gives us in our day to day radiology practice. This is a wonderful event especially for resident doctors because they get to present any article of their choice related to that topic and we have exciting prizes in store. So the registration for this program is free but mandatory. So we would request you to just come onto our website and have a look at the Google form and just type in your name and voila you will be part of the wonderful Journal Club that is going to start very shortly. The next program is the Masterclass series. You know that we have had these wonderful masterclass series both last year as well as this year. This year of course was just online but we are continuing the program with Dr. Malini Lavande as our coordinator for this event. So she has lined up two wonderful Sundays of a complete MSK overview. That again is a very basic fee so we would request you all to join in for that program. The third program is post Diwali and it is CT Buzz. So once again CT Buzz this time is online and hopefully this is the last CT Buzz that is online and we hope to go on site once again. We have Sandrad as our chief sponsor for this event and what we intend to do in CT is that we intend to make it a complete overview. So we are going to cover neck, chest as well as abdominal CT. So again this program will have papers, posters, quiz contests and the whole range of stuff that we always do. The last and not the least of course is Sonobas. So we have had two Sonobas so far one, the onsite one in 2019 December which was a great hit with more than 650 delegates. And then we had Sonobas virtual this Jan which had more than 2000 delegates registering for the virtual event. This time we are going to go hybrid. So it's a mixture of both online as well as onsite event and this is going to be in early Jan. This is Jan 8-9 and the details of this program will be coming up very shortly on our website. So stay tuned in with us and we will be giving you more information on all these events very shortly. Thank you and take care. Bye bye. Hi everyone. So the neat exam is over and as expected it was a balanced paper. I mean though the students are giving mixed reviews some are saying a very, very tough paper some are saying very, very easy paper. But as far as my understanding goes the paper. Hello everyone and welcome to Indian Radiologist. Today I will be taking you on a tour of all the activities and programs that are scheduled for this year as well as for early Jan next year. We begin the Indian Radiologist section with the Journal Club. Now the Journal Club is a unique program that has been crafted out and created by Dr. Mitusha Verma as well as Dr. Gauri Aguja. In this program what we intend to do on the third Sunday of each month is that we take you through interesting articles that are coming about in the world of Radiology. We will discuss them. We will dissect them and also look at what options that Journal gives us in our day to day Radiology practice. This is a wonderful event specially for resident doctors because they get to present any article of their choice related to that topic and we have exciting prizes in store. So the registration for this program is free but mandatory so we would request you to just come on to our website and have a look at the Google form and just type in your name and voila you will be part of the wonderful Journal Club that is going to start very shortly. The next program is the masterclass series. You know that we have had these wonderful masterclass series both last year as well as this year. This year of course was just online but we are continuing the program with Dr. Malini Lavande as our coordinator for this event. So she has lined up two wonderful Sundays of a complete MSK overview. That again is a very basic fee so we would request you all to join in for that program. The third program is post Diwali and it is CT Buzz. So once again CT Buzz this time is online and hopefully this is the last CT Buzz that is online and we hope to go on site once again. We have Sandrad as our chief sponsor for this event and what we intend to do in CT is that we intend to make it a complete overview. So we are going to cover neck chest as well as abdominal CT. So again this program will have papers, posters, quiz contests and the whole range of stuff that we always do. The last and not the least of course is Sonobas. So we have had two Sonobas so far. One the onsite one in 2019 December which was a great hit with more than 650 delegates and then we had Sonobas virtual this Jan which had more than 2000 delegates registering for the virtual event. This time we are going to go hybrid so it's a mixture of both online as well as onsite event and this is going to be in early Jan. This is Jan 8 to 9 and the details of this program will be coming up very shortly on our website. So stay tuned in with us and we will be giving you more information on all these events very shortly. Thank you and take care. Bye bye. Good morning everyone and a warm welcome to this academic initiative by Indian radiologist that is Radiology Journal Club. As Dr. Sanjeev Manisar already explained about the idea in brief, we are going to start this monthly academic event and we are going to try covering important topics on neuro radiology, musculoskeletal radiology, cross sectional imaging topics as well as breast imaging. We will be having our expert panelists joining for the discussion of these articles. The idea behind this is very simple. These are going to be short sessions of one one and a half hours. And as you all know that sub specialization is the way ahead. All of us like to subspecialize all of us would like to get updated, but in our busy practice, including for all our residents who are doing their busy duty schedules. It's difficult to go through these upcoming articles, research events and stay updated. So our aim through these journal club is to choose at least two of the relevant articles and discuss the highlights of these articles over a period of one hour. So all of us together can learn, can discuss and also can get an idea about future research and scope. Not only this we have decided to discuss few interesting cases at the end of the session, which may be related to the article discussion or maybe related to the modality or subspeciality which we are dealing with. And in future we also aim to discuss the cases from your end so all of you can share your interesting and difficult cases and our expert panel will be there to guide you through. So this is complete interactive learning package we would like to present to you all. And today we are starting with the neuro imaging part of the journal club, and we are thankful to our educational partners bears for their support because all these events are really not possible without the support of our educational partners. So the articles which we are going to take in discussion for today, one is a recent 2021 article on vessel wall MR imaging. So this articles talk about the integrities and tips and tricks for planning vessel wall MRI imaging with three Tesla MR scanners and how to mitigate various artifacts so we are going to go through this article today. The second article is specifically a revision article kept for our residents in mind because it is talking about 25 diagnosis, which can be easily made on midline sagittal image of the brain. So it will be a quick revision for all of us to see carefully a midline sagittal MRI image. And next week discuss to interesting cases where we have a long history and follow up some turns and twist in the story and then we will discuss two articles related to the diagnosis. So once again I welcome you all and all your feedbacks are welcoming and we would like you to please put your feedbacks in the chat box, make it as interactive as possible as we need to grow and improvise the program further. So today as I mentioned myself Dr. Mitusha Verma, I'll be taking you through these two articles and then interesting cases and I'm working as consultant radiologist at Nanavati Mac Super Speciality Hospital, Mumbai. So the first article we are talking about is a recent article published in 2021. And that is in the journal radiology. So the article can be completely accessed to the Google Drive link which we have shared on various social media platforms and also in the chat box so we are going to share a few of these are paid articles which we have downloaded to our paid access and few of the ones which we are going to discuss are open access articles. So this one was from the radiology through paid access. So you can actually download from the Google Drive link and you can read the articles completely whenever you are free to do so. So here this article has been published with the team of Dr. Kanth and Dr. Yeqau and they have been talking about how to improvise on vessel wall imaging. So all of us some time or the other we think that there is a plaque in the internal carotid artery there is feature suggestive of vasculitis involving the intracranial arteries like middle cerebral artery and we need to do vessel wall imaging. But a lot of time we feel that there are artifacts which are coming in or we also get confused by artifacts on the non contrast MR images. So let's see what this article has to say about it. So in their abstract or in their summary, what they have mentioned is that intracranial vessel wall imaging has become widely available in clinical practice providing multiple uses for evaluation of neurovascular disease. The vessel wall imaging study group of American Society of Neuro Radiology has reported expert consensus recommendation for the clinical implementation of the technique. However, as you all know that there is a little bit of complexity in the spectrum of disorders as well as the technique with some time make this little difficult for us. And the objective of this particular journal article is to develop a vessel wall imaging protocol that can identify intracranial vasculopathies and distinguish pathologic wall features from artifacts. So that is an important aspect they are discussing that there are many times it is either an artifactual to see a vessel wall thickening or artifactual to see dissection on top of images. Then how can we differentiate this between a true pathology and artifact identify reasons for flow artifact and describe techniques to confirm human patency and specify reason for vessel wall enhancement and its mimic and define techniques for distinguishing them. So, with this context in mind, let us move on to the actual article so I will just open the PDF file. So, this is our article, which we are going to discuss today so I have tried and highlighted the important key points and all of you also can go through the article in details as I told the links have been already shared in the chat box. So, a vessel wall imaging MRI has emerged as an effective method with which we can characterize pathologic features involving the vessel wall and detect lesions that can cause low grade stenosis and may elude angiographic detection. So, not only that we are characterizing plaques as we all know they say that it can also help us in conditions like vasculitis, moa moa disease, detecting angiographically occult atherosclerotic plaques and guiding biopsies for inflamed vessels. The ability to achieve these applications has been largely driven by the optimization of three dimensional high spatial resolution vessel wall MR imaging so we have to move towards 3D imaging high resolution 3D imaging from the routine 2D dataset which we can acquire for our routine patient but when we are doing vessel wall imaging we have to move towards the three dimensional vessel wall imaging. And also they have emphasized that administration of gadolinium containing contrast agent has proven to be essential in the detection and characterization of inflammatory vasculopathies. So always whenever possible when you are planning a study for vessel wall specifically try to perform it with contrast. Then what are the conditions which are going to create artifacts around the blood vessels so where important ones are the artifacts related to inadequate blood flow suppression so you know that the normal flowing blood will appear like a flow void. So if the suppression is inadequate we will see why we may think that the artery is blocked or thombost or has a plaque. Then there are issues with the spatial resolution specifically when we are imaging smaller vessels intra cranial branches of the circle of the list. CSF signal suppression that may be inadequate and because of which you may feel that the vessel wall is thickened and it is hyper intense and issues related to acquisition time. Sometimes the actual 3D sequence in the plane you want may take around 10 minutes of time and the patient also will not be comfortable doing such a long scan with multiple 10 minute sequences. So moving ahead what they are talking about is the technique per se because they need you to improvise on the technique as per the article. So evolution of vessel wall imaging technique from carotids to intra cranial vessels. So initially it was only the neck vessels which are also accessible to the Doppler imaging. So we know that even ultrasound Doppler can characterize vessel wall intimal thickening and plaques very well. But here we are looking to intra cranial vessels where MRI and the cross sectional imaging is the way ahead. So black blood MRI was established as a reliable and accurate method with which we can characterize carotid artery atherosclerotic plaque size as well as the composition. And we all know that we need to characterize the plaque content how by taking into consideration terms like presence or absence of lipid necrotic core and presence or absence of fibrous gap. So the delineation of the lipid rich necrotic core and overlying fibrous gap and the identification of intra plaque hemorrhage and calcification can be achieved by multi contrast MRI with which distinguishes features based on T1, T2 and proton density weighted images and your time of flight non contrast MRI and geography. Gadolinium based contrast enhancement improves the tissue characterization and can be used to identify markers of inflammation such as neo vascularization. So in short, they want us to do pre contrast T1, T2, PD and we know that PD facts at and T1 facts at are really important to image vessel wall. Then at routine top MR angiograms and then gadolinium based post contrast imaging. Next coming to a few important highlights of this article. So regarding blood flow suppression. So blood flow suppression is generally achieved by inflow blood saturation blood signal nulling by an inversion preparation pulse or the defacing of the moving spin. So you have a lot of sequences available as per the vendors which you are using for MRI scanner to suppress the blood and we call them as black blood MRI sequences. So the most common ones are the double inversion recovery. So flow suppression is a function of blood velocity and is more effective when the velocity is more than five centimeters per second. Now this is important that's why I have highlighted this. We all know that many a times when we do our routine top angios and when we do our routine T2 and flare, we may get some loss of fluid in the venous sinuses. And we may get idea or confused state we may achieve that there is a venous sinus thrombosis. So actually when the velocity of blood is less than five centimeters per second, they can be inadequate flow suppression. That is one thing to be kept in mind. Blood velocity often has a laminar distribution. So we all know that we have already in the physics part of the flow velocity techniques. So we know that physiologically when the blood is flowing through your vessels, it is slowest near the vessel wall and velocity is highest or optimal in the center. So that is why the suppression is going to be adequate in the central part of the blood vessel lumen. Whereas when it's going to be closer to the vessel wall, that is going to be the slow flow area, that time the suppression is going to be inadequate. And therefore you will have a feeling that there is plaque or circumferential wall thickening in these vessels. So disordered velocity distributions such as disturbed or recirculating flow can potentiate incomplete signal suppression at the periphery of the lumen which can mimic eccentric vessel wall thickening. So that is what I tried to discuss. Common side for flow artifacts include genu. So whenever the vessels are going to take a turn or whenever they are going to be tortuous. So include the genu of the pitra segment of internal carotid artery and juxta cellar cavernous segment of ICA. So you have to be careful in calling these areas with abnormal signal along the wall as areas of plaque or thrombus along the vessel wall. Going ahead we'll come back to this table of recommendation and avoiding errors and interpretation. But first let's complete this section of technique. Next important point they have brought is a vessel with a larger diameter related to the voxel dimension. We'll have blood protons located in the center of voxel that produces a stronger signal based on the voxel sensitivity function which is less effectively suppressed compared with proton in a small vessel with sub voxel dimension position near the edge or corner. So this is we are talking now we have shifted from that black blood sequence and we are talking of actually acquiring images of a vessel by placing it inside the field of view. So when the vessel is adequately sized inside the voxel, the proton spin which is targeted and the signal which we receive is much better as compared to the smaller vessels which are sub voxel in dimensions. So you can also utilize these terminologies while you are describing your features and artifacts. So specifically for our resident doctors and although confirming human potency on top MRNU scans can help avoid misinterpreting a flow artifact as a plaque. It is important to recognize that the same hemodynamic mechanism that is slow or disturb flow produces artifact with both of the techniques. So even the top is prone to the same artifact to which our routine black blood sequences are. For this reason gadolinium enhanced MRNU can help confirm human potency and this article has also quoted few more reference articles to substantiate this particular fact. So till now I think we can conclude that whenever we are planning a sequence or vessel wall imaging, we should try and also do pre as well as post contrast sequences. So now coming to this table where they have tabulated how to avoid errors in interpretation. So what is the artifact incomplete blood suppression mimicking atherosclerotic plaque and the solution is contrast enhanced MRNU. Similarly, circumferential wall thickening you to inadequate suppression of blood flow and again contrast enhanced MRNU. Incomplete blood flow suppression due to sequence orientation. So we'll see it later that the blood vessel has to be parallel to the frequency and coding direction and that will give you the best signal outcomes. So the next tip or trick is you have to make your blood vessel plan such a way that it is parallel to the frequency and coding direction in the field of view. Vessel crossing through the leptomeningial enhancement mimicking vascular. So actually this table they have kind of summarized everything out of the text. So we can actually go through the table at the end. So we discussed about the artifacts in the black blood sequence and here is the example you see that they have pointed out a tortuous vessel. And in this suppressed black blood MR sequence you see that there is some area of abnormal wall thickening as it appears to be on the coronal image in the cavernous segment of the ICA and even on the sagittal. Here is the top image where we again see that it looks as if there is a luminal narrowing because of the thickening. But when the contrast has been administered that artifact has what mitigated. So that is how important it is to exactly identify the luminal narrowing and talk about it. So next important thing is that your vessel orientation should be parallel to the readout frequency and coding direction. Frequency and coding gradient pulses used in the direction of blood flow can induce strong non-mel gradient moments that result in more signal attenuation in the readout direction than the phase or section. So you might be feeling that why are we reading through the lines and so that is the entire concept of this journal clubs. We are usually busy not to go through each and every part of the article. So we are aiming to read the articles for all of you highlight the important points and then we are going to provide these articles to you beforehand so that you also can read if you want and then actually we can discuss the important points. So that every month at least two articles we have gone through and we are updated at least with two recent developments. Blood flow suppression on 3D vessel wall MR scans can be further improved by using preparation pulse module such as motion sensitize driven equilibrium which uses flow sensitive defacing gradients and to suppress moving spins. This technique has been used to image brain aneurysm but with noted signal to noise ratio reduction. So a lot of vendor specific newer sequences have been added with little tweaking into the basic physics and techniques and you can utilize them you can talk to your application specialist and understand which of the sequences can be used for high resolution vessel wall imaging. So here again an example where you see that they have shown coronal image and there is thickening which is circumferential involving the cavernous segment of the ICA. So it appears that the entire cavernous wall cavernous segment of IC has a thickened wall but when you see the post contrast you see you can actually see the symmetry and you understand that that is also artifactual signaling which is seen and it appears as if the vessel wall is thickened. So not that all the patients we can give contrast but whenever possible and whenever important specifically like suppose you are dealing with vasculitis or indications like that always try to perform a complete scan using contrast as well. Then CSF signal suppression is important spatial resolution is important going through these quickly CSF signal suppression delineation of the intracranial arterial vessel wall or MR scans for vessel wall can be optimized by suppressing CSF signal surrounding these vessels to highlight the outer wall. Now what we are using is the case space that all of us know so what importance of this paragraph is that CSF signal suppression is also important otherwise we can get artifactual appearance of hyper intensity along these blood vessels. CSF signal intensity can be attenuated by selecting a short repetition time of 800 to 1000 milliseconds going to the long T1 value of CSF. However signal loss from T1 weighted imaging which you are going to perform is an untoward consequence that limits the ability to resolve the thin walls of intracranial artery. So you have to get into a balance between these two but that is important. So whenever as a radiologist you are monitoring the scans and you are seeing that the vessel walls are thick and vessel walls are hyper intense try to make sure that these artifacts are not playing role and it's an actual pathology. Spatial resolution partial volume averaging due to inadequate spatial resolution is frequently encountered with intracranial vessel wall MRI specially considering the range of wall thickness encountered in the intracranial circulation. So what we are dealing with a very thin walls 0.3 to 0.6 millimeter relative to the optimal acquired resolution of our machines that is 0.5 millimeter isotropic at 3 Tesla. So that is what is causing the issue with the spatial resolution and for this reason a field strength of at least 3 Tesla is considered necessary for adequate intracranial vessel wall. So coming to another important point as compared to 1.5 Tesla 3 Tesla imaging and scanners will give you a better quality vessel wall and actually optimal quality vessel wall imaging. Intracranial plug components might be identified very well as they are in the intracranial carotid plug by vessel wall under ideal MRI condition particularly because these vessels are larger. But if you have to talk about the compositional characteristic it might be difficult if the spatial resolution is not that great. Now you see another example of this images for talking about the direction as we discussed frequency encoding direction. So the vessel has to be parallel to the frequency encoding direction when the planning was not adequately parallel to the frequency encoding. You may feel that here they have shown the DSA with the cross sectional where this actual images from and you see it appears as if the vessel wall is thickened. But actually it was just because of the artifact again basilar artery or the cut section. In the this image you see that there is wall thickening which is artifactual because of wrong planning and now when you see the planning direction made parallel to the frequency encoding you see that the vessel wall is very clearly see. This may not be very commonly used in our day to day practice but I'm sure that if you are in a busy MRI setup at least once in a month you get request for vessel wall imaging. Otherwise as well you might get plaques or vasculitis like phenomena patients nowadays are increasing like temporal arthritis, headaches, young patients with stroke where they are suspecting in fact secondary to vasculitis. You might go ahead and actually advise doing vessel wall imaging so it's important to learn the technique. And here is another example where we see that artifactually the vessel is appearing bright but when the planning and the direction has been made proper and when we have utilized when the specific high special resolution sequences we can actually see the vessel very well even the smaller lenticulostride branches. Next thing is that the artifact from the small veins so as we know that vessels are close by the arteries and the veins so artifactual enhancement in small veins due to slow flow can easily be mistaken as eccentric arterial wall enhancement suggesting atherosclerotic plaque so be careful about the veins and you can actually go back to your swan sequences and see whether it's an artery or it's a vein it can be easily differentiated on the two. The acquisition time already I spoke about when you are aiming at a very high resolution the acquisition may go as high as 10 minutes. But ideally they are talking that the acquisition should be in the sagittal plane but they are saying that if you do it in the coronal plane it can be reduced to 5 to 8 minutes. So if you have time doing a sagittal plane if you don't have time at least do a coronal plane 3D imaging which can be reconstructed. This is the artifact of CSF inadequate suppression where you see when they have transversely seen this particular MCA branch and the CSF is not suppressed fully. It appears as if there is a hyper intense rim along the vessel wall but when the suppression is adequate we can actually clearly see the interface. There are very small things and that is the aim of the journal club that we might not be reading the entire vessel wall imaging technique every time but at least if we go through the discussion few tips and tricks we can take through and utilize them. So here is another example where we have few images talking about the artifactual enhancement and artifactual hyper intensities of plaque and they have been mitigated by using proper planning and techniques. Next is a lot of vendors including GE what we are using they are coming up with technique known as compressed sensing reconstruction. So they are giving us all these upgrades in the machine already the software and the hardware upgrades where actually what it enables us is an accelerated MRI experience. By nonlinear interactive reconstruction of sparsely under sample case based data compressed sensing has been widely implemented in different clinical application and it has also been used to accelerate carotid plaque imaging. So this is something which is coming up which will give us the faster sequences basically because it is going to utilize the case based better and also the sequences will be of a greater resolution if properly planned. So vessel wall enhancement now we are coming to the next part of that is our enhancement vessel wall enhancement varies depending on the underlying vasculopathies and the relative sparsity of vasovisorium of the intracranial arteries under normal condition and its development in the setting of vasculopathies. So when the vasculopathies set in when there we have vasculitis that time we have abnormal vasovisorium developing along the vessel wall that will lead to the enhancement. So let's see what is the physics and pathophysiology behind the enhancement to understand abnormal conditions. Other factors that are thought to contribute to abnormal enhancement are related to the level of inflammatory activity because of increased endothelial permeability and new vascularity. So that is the cause of your vessel wall enhancement increased vasovisorium vasculopathy increased permeability of the endothelium and new vascularity. This enhancement is characteristically transient and is associated with the active phase of inflammation. So that is what your rheumatologist will be asking you is the vessel wall enhancing. So there they want to know about the active state of inflammation. The degree of enhancement may be attenuated by steroid therapy and that is what again MRI will be important to follow up these cases. So sometimes the artifacts as we are going to see through even in the post contrast imaging you can get artifacts and that can mimic abnormal enhancement. Now also they have been mentioning what is the time delay between the contrast injection and acquisition of the image and they are taking it ideally as a five minute delay following the contrast administration. A few articles are talking about double dose of contrast but routinely in our practice we have seen that even the routine calculated dose is enough but this is one important point it has to be a delayed acquisition. The 3D vessel wall MR scan has been used to identify vascular inflammation based on the segmental concentric enhancement. However it is important to recognize that blood vessel coursing through the leptomaninjel enhancement. So sometimes there may be underlying leptomaninjel disease and leptomaninjel enhancement commonly seen in the settings of inflammatory diseases can result in false positive appearance of vascularitis. So per se it is not vascularitis. Awareness of anatomic structures and scrutiny of the appearance of oblique reconstructed scan images are essential to mitigate this. Then there may be possibility that there is a thrombus with recanalization versus abnormal enhancement. So when interpreting post contrast images for suspected inflammatory vasculopathy so we are actually dealing with two different conditions inflammation versus a thrombosed vessel which is recanalized non-inflammatory. So inflammatory vasculopathy a potential challenging task is to differentiate inflamed vessel from enhancement of an organized thrombus. So that is one of the differential which you should be taking care of. This is what they are showing is the leptomaninjel abnormality mimicking vessel wall enhancement. Another thing is here you see a thrombus which has recanalized and what will differentiate that too. Because if it is going to be a thrombotic event you may get presence of small infarcts around the vessel even on your swan images you can actually see area of blooming within. Micro hemorrhages with surrounding enhancement very important tip sometimes micro hemorrhage can have inflammatory cell density around it and that can relate with the enhancement. So post-mortem studies have shown that increase in the density of inflammatory cells near micro bleed lesions and this inflammatory response surrounding the micro hemorrhage however may resemble an inflammatory process involving the vessel wall. So this is something relatively new to learn that the micro hemorrhages can mimic vessel wall inflammation and micro hemorrhage can be easily distinguished on your susceptibility weighted images. So that is one thing it can be really challenging in patients with myeloid angiopathy because we know that in these patients we have multiple micro hemorrhages so they will be bound to be close to your blood vessels and a lot of artifactual enhancement. Parenchyma enhancement in subocute infarcts so all of us know that vasculitis itself is a risk factor for causing infarcts in the brain and the infarctal brain parenchyma in the subocute phase will enhance because of disrupted blood brain barrier. So again we have to be careful compare with the diffusion part of it see the blood vessels carefully on the reconstructed axial images and confirm about the vessel wall enhancement. Sometimes there could be abnormal vascular plexus which can create abnormal enhancement so vessel wall enhancement not attributable to vasculopathic changes can be identified due to enhancement of the vasovastorum or a vascular plexus. Now that is important anatomic point that it is present only in the extra cranial arteries and not typically in the intracranial vessels in healthy young adults and children. However vasovastorum can communicate with the extra cranial vascular plexus and follow arteries as they enter the intracranial compartment. So very commonly with the V4 segment it can be seen so that is important to note. So here you have one micro hemorrhage which is mimicking all vessel wall enhancement and actually it is nothing but a small tiny focus of micro hemorrhage. This is in fact a brain parenchyma with enhancement which may be going along the blood vessels and you may feel that this is vasculitis with vessel wall enhancement. Sometimes you can have nodular thickening and enhancement from a varix or ganglion and that can also create a mimic curve for these abnormal vessel wall enhancement. Very commonly seen in cisterna magma again along the V4 segment of the vertebral artery. So protocol recommendation and clinical applications so given the unique histo anatomy of the intracranial arteries and the disease specific to these vessels along with the artifact. Frequently encountered when imaging these small tortuous structures a protocol should be designed so as we saw the artifacts and they are talking about designing a protocol. And this image is about that varix around the vessel and this is not abnormal plaque or vessel wall thickening it is just a varix. So let's see the protocol and as we said that we'll review the table at the end of the article so this is the table. So go for a contrast MR angiogram to adequately get the idea of the human size and presence or absence of thrombus within. For incomplete blood flow separation due to sequence orientation make your blood vessel parallel to the frequency and coding direction vessel when they are crossing to the left two managers can mimic vasculitic enhancement so evaluate reconstructed images. Thrombus with recanalization can mimic vasculitis so maybe unavoidable sometimes but biopsy confirmation which is very rarely done micro hemorrhages so that can be differentiated using your swan images. Parent camera enhancement in subacute is gimmick stroke mimicking vasculitis so that can be again correlated with diffusion and the history of the patient. Venus flexes enhancement can mimic vasculitis so you have to reconstruct and see the anatomic site. Focal benign nodular lesion at the foramen magnum that can be just a venous varix. Venus enhancement again you have to reconstruct and see the images. So that is how you have to plan your vessel while imaging first you will perform your pre-contrast sequences routine tough imaging and understand which part of the vessel is deceased and you want to see in details. After that you're going to plan high resolution sections using your pre-contrast even T2 PDPD fat set sequences swan and diffusion will be a part of it and after that you are going to go to the contrast. As and when possible go for 3D sequences we have all high resolution 3D sequences now available. The scanner which is better is the 3 Tesla scanner right now as compared to the 1.5 Tesla scanners which you have and also acquire the sequences in 3D plane in pre-contrast as well as in post-contrast. This is the basic protocol recommendation they have given and you can actually see this in the article links which we have already shared. So no need to copy from here but you can get an access to the complete article. So I think with this we can conclude and come to the summary. So a curate interpretation of the intracranial 3 dimensional vessel wall MR scans in clinical practice relies on an ability to recognize pitfalls that arises from incomplete flow suppression, insufficient spatial resolution or misinterpretation of enhancement and an understanding of the requirement for the technical adequacy. So this is also one of the role of radiologists because nowadays we know that even the neurologist can read the MRI images very well but this is where we are important. They can actually understand the pathology but they might not understand the mimics and the artifacts. So here we are to explain it to them that see this is artifactual and this is the actual pathology which you have to deal with. So that way we will make sure and understand only when we know the basic physics and technique. These preconditions highlight the need for optimized sequences appropriate to the diagnosis in question and adequate training to identify pitfalls and interpret examination results correctly. So these are the main highlights of this article hope we revised it and it will be helpful to all of us. If you have any discussion points you can put it up in the chat box and I would request you all to go through this article once whenever you feel you are free to do so. Now with this I would request Dr. Gauri. If Dr. Patkarsar is there with us so can join us for a few minutes and then we can go ahead to the next article. Yeah Mithusha, Dr. Patkarsar is on line. Good morning sir. Good morning. Thank you Mithusha for fantastic reading and choosing the appropriate topic. Dear friends and colleagues we welcome you to this new academic endeavor under the ages of Indian radiologist the radiology journal club. This is Dr. Shilpa's idea which we took forward Shilpa is here. I'm sure all of us agree that subspecialization is the way ahead in radiology and keeping ourselves updated with advances is critical for being relevant today. 30 years back we could rely on textbooks and museums. Today radiology changing so fast that it's just impossible to rely on textbooks and what your seniors teach you. It is extremely difficult to keep in pace with upcoming research and recommendations specifically when we are busy in our routine radiology practice whether it is diagnostic or interventional. The amount of information we as professionals are expected to master is constantly increasing in this modern information-driven environment. I tell everyone X-ray machine which you bought at the beginning of your practice could last through your practice. Ultrasound CT MR and today even X-rays have changed the way we practice their lives are getting shorter and shorter and our profession life is also getting shorter and shorter and if you want to enhance that reading, reading and reading and getting information is the only way forward. We with these monthly Radiology Journal Club aim to bring to you an easy access to relevant and authentic updates by reviewing ongoing research articles and critically appraise existing literature. We will try to cover as vast spectrum in radiology as possible. Today we started with neuro radiology. Shilpa will do breast imaging and we are shortlisting some seniors for other cross-sectional imaging, musculoskeletal imaging etc. In this format we will discuss the highlights of two recent articles and then our experts will discuss approach to few interesting cases. We will share the articles in advance for access to all of you. Also, I would like to take this opportunity to remind you about upcoming MSK masterclass scheduled on 30th and 31st October 2020 which will be conducted by Khamarni. CT births between 12th and 14th November. Registration for both these events is on and links will be shared in the chat box section. I thank you all for your constant support to all of our endeavors. Our YouTube channel, Indian Radiologist already has over 450 academic videos. We now have over 29,000 subscribers and already crossed approximately 1 million views which is a big milestone. We are thankful to our educational partner for today, Bayez for supporting the Radiology Journal Club initiative. Kedar always looks forward to all these new initiatives. We would definitely intend to evolve and improvise and therefore secure genuine feedbacks and inputs. Mithish will give me a couple of inputs as to how orthopedic is doing this and we will try to work on improving what we are doing today. To end, I would like to quote what Amy Poil said. Always find a group of people who challenge and inspire you, spend time with them and it will change your life and help you evolve. And we at Indian Radiologist are the group which includes Mithusha, Gauri, Dr. Sanjiv Mani, Dr. Jignesh Thakkar and Channel Singh. Look forward to evolve Indian Radiology as much as we can. Thank you all for your attention and attending this today. Thank you sir for always guiding us through new ways of developing ourselves academically and also to help our colleagues do so and learn from them as well at the same time. So with this idea, as I said, we are looking forward to your feedback so please do come up with the ideas you would like us to incorporate in these journal clubs. And the upcoming journal clubs specifically for the breast imaging, cross-sectional imaging are going to be really good interactive sessions and we are going to see approach to various cases and new upcoming articles and their review. So looking forward to all these journal clubs and for your all support. So sir can we move to the next article and then the case? Yes please. So with this now it's time to review the second article which I already told that it's going to be a revision for most of us and it's specifically meant for the residents who are listening to us today. So this article is about 25 diagnosis which can be easily made on a mid sagittal brain MR image. And before we go ahead again thanking bears for their support and they have come up with this excellent contrast molecule, Gadowist, and we have been using it as well. So this is how it works and we have been shared important notes about this particular molecule which we will be sharing with you as well so you can go through and utilize in your clinical practice. Now the second article as I was talking about is an article with 25 diagnosis on midline images of the brain from fetus to child to adult. So what this article does is first of all it starts with the anatomy. So it talks about what all can be actually identified as a normal anatomic structure. So one of the most important sectional planes in neuroimaging is the mid sagittal brain. So if you are a resident just joint radiology or if you are planning to appear for your FRCR step one where anatomy is a part, this is one of the most important section to go through. A good working knowledge of the normal neuron anatomy of the mid sagittal is essential so that the subtle abnormalities that may manifest can be easily recognized here. So how many structures can be actually identified so this article tells us like 87 structures which can be seen on this particular single image of mid sagittal brain. So various parts they have marked you can actually revise them whenever you want and go through them. We can just see few of these uncommonly used or the important ones so we know this is the corpus callosum and various parts of the corpus callosum. The extension of the corpus callosum the genu ahead here a 46 number is the anterior commissure. And here you have another structure number 49 which is your mammillary body. Then you have this structure here 18 number. So this is your planem sphinoid day. So I have not taken all of them to be discussed right now because we have to discuss mainly the diagnosis which can be made. So this is how you can go through the particular anatomic depiction that like 26 numbers or they have marked out here which particular structure is the 26 mark with an arrow so this is the Bayesian. And here we have just behind it in the dorsal aspect that is the opistion. So Bayesian to opistion you have your macroe line and then you can identify whether there is inferior tonsillar herniation or not. Similarly you have various systems and various spaces of CSF which can be seen on mid sagittal. This is the area where you have the fourth ventricle. This is the aqueduct so whenever you are doing your planning for CSF flow study the marker or the planning has to be perpendicular to the aqueduct over here. This is the quadrigeminal system which is marked as 63 so you can have structures like quadrigeminal plate lipoma which can be present here. Section number 77 is the tentorium so you can have your meningioma sometime based along that particular tentorium leaflet. This marked as 70 is cuneous here and here another thing an important guide is to know is the cingulate guide is marked as 66. So many structures are there. I would request if possible for the residents please go through this article for the anatomy as well. Various cisternal spaces as I told so if you do a sagittal thin T2 weighted sequence or if you can do a 3D fiesta as it's known on G or cis sequence as it is known. You can actually see the various cisternal spaces very well and you can comment upon presence of things like web in the region of aqueduct or in the cases of aqueductal stenosis. Even here you can see that there is presence of a cyst in the region of the pineal gland. So now with this let's move on to the actual part of the article where they are talking about the various diagnosis. So let's go to the PDF. So this is this article. So the first part we already discussed we discussed about the anatomical sections and various things which can be seen on this mid sagittal brain. Now let's see to the diagnosis. So it starts the division which they have taken in is corpus callosum related entities so one after the other. So corpus callosum related entity starts with urgenesis of corpus callosum which is a common diagnosis in pediatric age group. So you can see on this image that it's looking abnormal and definitely we can make it out. So there is complete urgenesis of corpus callosum but not only in a pediatric brain but also in your fetal MRI as you can see. That we can actually identify complete urgenesis of corpus callosum and then the radial orientation of the gyri surrounding it. So the cingulate gyrus which we had identified. Next is corpus callosum lipoma. So on your sagittal T1 weighted image you can beautifully see this band like hyper intensity which is fat containing tissues lipoma. Sometime it can be completely encircling the corpus callosum sometime can be a very small component somewhere around the corpus callosum. Now this is another thing which they have marked and what is this? There is some hyper intensity in the region of splenium of corpus callosum and genu of corpus callosum and there is a small scalp hematoma they have marked with an arrow. This area of altered signal intensity is also showing restricted diffusion which again they have done a diffusion sagittal plane and showed it to us and this is diffuse axonal injury. So with this we come to revising another entity known as transient splenial hyper intensity. Transient splenial hyper intensity as we all know is also known as the cytotoxic edema of the corpus callosum. It is a transient phenomena which can be seen with lot of conditions like post ectal state like viral encephalitis, like states of post like metronidazole toxicity sometime just because of certain drugs it can be seen. Some metabolic disorders can also cause transient spenial hyper intensity. Euremic encephalopathy can cause transient spenial hyper intensity and if you follow up these patients after 2 to 4 weeks you will see that it has reverted back to normal. So that is one thing which you can see. Now coming to so this is actually how they have pointed out the transient spenial hyper intensity. Next coming to the cellar and entities related to cellar and paracella region so ectopic neurohypophysis. So we all know that in a sagittal T1 image the neurohypophysis posteriorly has to be hyper intense the posterior pituitary bright spot should be seen in its normal location which is here. Along the posterior part of the pituitary gland here you have the same ectopic bright spot seen much higher up the infundibular stalk or axis. So this is seen in cases of diabetes insipidus and this is ectopic neurohypophysis you can identify this clearly. Here you see a cystic heterogeneous partially calcified relatively thick wall peripherally enhancing lesion in the supracellar area and the pituitary gland is seen separately. Now this is a cranial pharyngeoma. So basically if it's any pituitary or cellar supracellar lesion it can be very well picked up on a mid sagittal image. So there are cranial pharyngeoma they have taken as an example. Parcenter media cysts. So many a time these cysts may be missed but if you see carefully through your sagittal image because axials may be creating a lot of volume averaging and sometimes the sections might not go through the pituitary gland or area in the cellar. Sagittal will always show you the pathology very well. Even coronals will not we may miss it sometimes in the coronal. So a parcenter media cyst which is a periphery enhancing simple cyst can be seen in this region. Radke clef cyst. Then next is your hypothalamic hamatomas which presents with gelastic seizures very well defined homogeneously iso to hyper intense area which is seen along the hypothalamic axis and this is a hypothalamic hamatoma. Sometimes they are not this big they are usually small in size so you have to be just carefully looking for them. So then the next they are talking about is persistent cranial pharyngeal canal. So the invagination of Radke's pouch from the nasopharyngeal miposa to the cellar terseca takes place with a cranial pharyngeal canal a developmental defect in the basis phenoid. So that can be sometime seen on your CT scan images like this. So this is not a fracture. This is persistent cranial pharyngeal canal. So this is the most commonly incidentally seen finding the pituitary gland may protrude into the canal possibly with associated endocrine dysfunction. And there may be an associated sphenoid meningocelor encephalocene going through this canal. So this is the importance of this remnant canal known as persistent cranial pharyngeal canal. Then you carry malformations which we can see good and we can very well see them and appreciate them on the mid sagittal image where you have to actually see the inferior tonsil or herniation of the cerebellar tonsils below the macrae line. There are various lines and it is difficult to remember but I feel that macrae is the easiest one. So it starts from the opistion to the vasion here and the cerebellar tonsil should be above this line. When it goes below this line, this is abnormal and the tip of your dance should be below this line. When it goes above this line that is abnormal and that is basilar invagination. So any two malformations can be also seen with presence of small encephaloceles. Megasisterna magna is one finding which we often see in our day to day practice. So presence of prominent CSF space, retrovermian erychnoid cyst. Another very commonly seen and both of them are confused between each other. Megasisterna magna and your retrovermian erychnoid cyst. So as we know erychnoid cyst will cause scalloping of the bone margins. So Megasisterna magna will not cause osciss remodeling that much and this will go more like on either side of the midline. Here we might see something septation within. So that is how you differentiate. Many a times it's not even important to differentiate and these are just incidentally picked up. The antivocal complex can be traced back to the mid sagittal brain sections and we know that what are we looking at. You have turned a portion of your cerebellar vermice, hypoplastic abnormal vermice. The posterior fossa CSF space is widened and you have to talk about the torcula. So everything is there in your mid sagittal single section image. Next you can talk about rhombin keyfellow synapsis. Again it's a midline fusion abnormality of the cerebellum and there is non development of the vermice. So there is a fusion of the cerebellar hemisphere. Then go back to the pineal region and you can see the cyst over there out tumors like pinealoblastoma. This is a proper antivocal malformation. You see the upturned torcula and a big CSF space in the posterior fossa. Opening of this space into the fourth ventricle and they have given here image of the rhombin keyfellow synapsis. Where the vermice is absent and the cerebellar hemispheres are actually fusing with each other in the midline. A small simple cyst which we saw ahead of the slides also here in the pineal area. But actually you can get proper tumors like pinealoblastoma, germinomas in these locations. So again this is an important section. Not only the diagnosis of the masses but also of the vascular malformation. So some of these are exam spotters and some of them are really easy ones to attempt. So this is typical venofgalin malformation. You can see a abnormal flow void here. This image they are showing of estasis sequence at midsection showing your thin web in the aqueductal stenosis. So earlier when the resolution of the MRs were not that great, it was thought that it is some congenital anomaly aqueductal stenosis. But actually now with the thin sections and 3D images we can see that it is at presence of these webs which can cause the flow related abnormalities in the aqueduct. Tectal plate glioma where we don't even need a biopsy. It's a complete radiological diagnosis and the location is very, very typical. Then retroclival epidural hematoma. So even that can be seen on the midsagital image. This is how it looks like. So some hyperdensity on the CT in the retroclival region. And similarly on MR. So we have to carefully look for this abnormality. One more tip is that you will identify these subtle abnormalities only when you have seen the normal brains a lot many number of times. So whenever you are free going through your normal scans, you know it is headache protocol looks normal. Try to just revise your anatomy. Try to see how normal structures look like. And if you train in that ways you will definitely pick up abnormality very quickly. If there is something like a sliver of epidural hematoma, some abnormal venous varix, you will see the abnormality very quickly. And this is suprasijatal sinus thrombosis with the absence of flow on the sagittal image. This is T1. So here you see the hyper intense thrombus. So this article quickly revises so many diagnosis which can be made in a midline sag. So it's a quite interesting and easy article to go through. And they have left a few more diagnosis and they have just mentioned the names like intrafalosil, which can be at various parts. Then atreatic defalosil, pituitary adenoma, then pitusitoma, then chiasmatic glioma, tectilipoma, and the assessment of the vellum interpositum, clivalcordoma, clivalchondrosarcomas, colloid cyst of third ventricle, basilar apex aneurysms, septo-optic dysplasia, multiple sclerosis midline sag flare with pericalosal lesions, suzaxinro, marquiafava, bitnami, which is with the alcoholics and you see again transinsplenial, hyperintensity, periaquoductal abnormalities, estesion, uroblastoma, then all these things can be identified in the midsagital brain. So I hope this quick revision of so many pathologies on one image helps you out in your routine practice, specifically to our new radiology residence. So this was about the two journal articles which we reviewed today. And now with this moving ahead to case discussion. So we had planned actually 20-20 minutes for the journals, but it little bit overshoots. So I'll just quickly take you through the cases and let's keep it little interactive so you can bring your diagnosis, your ideas in the chat box, so free to do so. Please put your initial diagnosis, differential diagnosis which you feel into the chat box. These cases I have kept like the complete stack of images are there on the DICOM folder. So we'll go through one by one findings. And the first case is of a 48-year-old gentleman who presented with blurring of vision, headache and all the sensation over right half of phase since past 15 to 20 days. No co-probabilities of concern and the immune status for this particular gentleman he was an incompetent guy. So we have many follow-up scans. Basically now we have been following up this patient every six months or so. But three scans we will discuss today. The index scan done outside the one scan which we did after one month as a diagnostic scan and then a post treatment follow-up. So let's move on to the DICOM file for this patient. So these are the images and I've just downloaded the entire DICOM and opened on radian. And I'll just take relevant sequences first. So starting with the actual T2 weighted sequence. Now this is a 48-year-old gentleman as we discussed. So what we can see here is presence of this asymmetric T2 hyper intense areas. In bilateral, centrum semi-oval corona rariata. Basically periventricular white matter involvement. Even going into the midbrain and these are asymmetric. So I think that is what we can see on T2. Moving ahead we have flare and on flare these are again better seen. So here these are the abnormal signal intensity areas. Young gentleman absolutely normal over the past years and now developing these abnormal areas. So you can see this in the corpus callosum as well. But the complaints are mainly related to a vision and sometimes abnormal sensation over the face, sometimes imbalance. Going ahead. So coronal sequences have been performed T2 weighted and these are again the same areas very well seen. If you people can identify anything else abnormal signals changes you can just put that in the chat box. Diffusion. See how confluently we can see the area of abnormality on diffusion weighted sequence. Here it is. Then thin sections were obtained from the CP angles because imbalance was one of the findings. Now this scan was done somewhere outside. If you can make out just see that there is some asymmetry in the fifth nerve root entry zone area and in the area where you can see it in the Meckles cave. Again putting that image here. So this is right-sided trigeminal nerve which appears little thickened as compared to the left. This I can say retrospectively because I have seen the post contrast we will see later. So this scan they just did MR and you and no contrast was given and this was the finding spectrum any particular diagnosis which you people can think of. So you can put up in the chat box. I can see people raising hands. So you can put your answers in the chat box. Dr. Ashwin you want to add something to it. Those of you who want to discuss and talk about it can raise their hands or you can put your diagnosis in the chat box. So now let's move to the next image which we have with us. So this patient now came to our hospital and now we added contrast sequences as well. So I will just go through the contrast and this scan was done one month later as compared to the previous image what we saw. So this is what the T2 again those confident white matter hyper intensities are seen little bigger than what they were before. But let us go through the post contrast things. See carefully this is 3d T1 post contrast and what you see is there is abnormal enhancement in that thickened trigeminal nerve here. Not only that nerve but also your 7th 8 nerve complex here. This one is thickened and it is enhancing abnormality. This segment of the facial nerve should not enhance and this enhancement is abnormal. Again this right sided facial nerve segment is also enhancing 7th 8 nerve is enhancing. Those areas of white matter hyper intensities are not showing any significant enhancement. But what we pointed out was multiple cranial nerve thickening and enhancement. So let's see that on coronal as well. Here we are. So this is the enhancement in the 7th 8 nerve complexes which we saw. And here this is the enhancement of the fifth cranial nerve in the trigeminal nerve roots root entry zones. We went ahead did a spectroscopy. What was there was an elevation of Pauline over creatinine. A limited lipid lactate peak which would be identified. We also went ahead and did screening of the spine. Spinal cord per se did not show much of significant findings. So these are the image findings. So people are coming up with the diagnosis. I can read it out. Hypoplastic right vertebral trigeminal neuralgia and multiple sclerosis. So great but trigeminal neuralgia will not explain the 7th 8 nerve thing. So basically we are going through a case where we have multiple cranial nerve thickening and multiple cranial nerve enhancement. So Dr. Sapna is talking about multiple sclerosis which is a very good differential. And that is what the first scan was reported as. The first scan was reported as the demyelination. But the conditions kept on worsening. And that's what brought the patient to this particular second scan. So now the approach which we followed was differentials of multiple cranial nerve thickening and enhancement. And in our experience this was the third case of similar findings. So the differentials for multiple cranial nerve enhancement. First differential for this age group you can keep is lymphoma. So sometime primary CNS lymphoma can present with multiple cranial nerve enhancement and thickening. The other differentials are neurosarcoidosis. So that is also a good differential to go with for multiple nerve involvement. Now the problem with this patient was how do we prove the diagnosis? Because if they want to undergo treatment for lymphoma they need some diagnosis. Some tissue sampling, some diagnosis so that they can go ahead with the chemotherapy. And if it is just neurosarcoid the treatment will be definitely different. So PET scan was done. In case we could find some other focus in the body and biopsy that but PET scan was negative. Definitely PET won't be very sensitive to show up the cranial nerve abnormality. And what was done next was CSF was taken out and flow cytometry was performed. And that showed features of increased lymphocytes and all the features suggestive of lymphoma. So the diagnosis was made which was correct as we were following this patient for treatment follow-up and outcomes. And this is one of the follow-ups I have kept in April 2020. So that was August 21. This was April. So almost eight months apart. And you can see those wide matter hyper-intensities they have responded very well. They have reduced. There is an area of abnormality which is here in the corpus callosum spenium going on to the left side. But if you see the post contrast the same sequence let's see. And let's see what the cranial nerves are looking like now. So the seventh-eighth nerves going up and the fifth nerve here. So the enhancement has completely resolved. So this was primary CNS lymphoma presented with multiple cranial nerve enhancement and thickening. So this is one of our cases and I just quickly go through the second case which is a similar spectrum. So as I told this was our third case and over a period of time there were six cases. So we already have submitted this as the case series for primary CNS lymphoma presenting as cranial nerve abnormality. So this is 79-year-old gentleman presenting with progressive imbalance over a few months. And this person had diabetes and hypertension and immunologically a competent person. Again multiple scans and the biopsy was delayed in this particular condition. The journey started in January 2017 and went across to 2018 almost one year complete when the final biopsy was actually performed. So I will just quickly show you the images of this patient. So the first scan which was performed was in January 2017. And this person came with main complaint of imbalance. So T2 weighted axioles if you go through quickly one loop you may feel that it is just some mild age-related atrophy and all changes. See this one bright spot in the cerebellum which we passed off as old in fact. The first reading it was passed off as old in fact. See diffusion because in old age some weakness something first in fact can be finding but that area is also showing restricted diffusion. Old in fact subacute in fact cerebellum in fact and that can explain the imbalance. So we were quite okay that old person with cerebellum in fact. See one more thing which you incidentally whenever you have imbalance patient you do this fiesta sequence to rule out cp-angle lesions and schwannomas. And you see some thickening in the left cp-angle intramural component here which is not there on the right side. So most commonly it has to be vestibular sonoma. So that was the thought process a small in fact in the cerebellum and a sonoma contrast was given. So we were waiting for creatinine. So this person was again taken for the scan and this is the contrast. So you can see your this is the enhancement in the thickened component of your vestibular nerve we thought so it's a vestibular sonoma. But to our surprise even that small cerebellar in fact was enhancing or whatever it was hyper intensity it was enhancing. And we thought that still it could be subacute in fact. But when we scroll through we could find even smaller similar areas of enhancement in the cerebellum at this point of time. This was the only thing which we could think of and we just gave all the findings into one and asked for follow up. So now let's see what happened in the follow up. So this person was sent with the complaints for the vestibular sonoma. He was referred for ENT reference and the expert advice from the ENT surgeons. They didn't feel that it is actual vestibular sonoma clinically or because of the symptoms. So he was kept on follow up. Now this is the follow up and now you see the change that was January and this is April. That cerebellar lesion which we thought small subacute in fact has grown substantially with a lot of mass effect and in a span of just three months. So you can go through this and showing you the coronal T2's here. You can actually see some lesion out there with a lot of perillational edema. Let's see contrast here. So big lesions heterogeneously enhancing lot of edema around the lesions and substantial interval increase in size. Somebody has tried taking out sample out through the 7th, 8th thickening nerve thickening. They found out it was some abnormal cells non specific not vestibular sonoma and lot of postoperative fluid in the mastoid. Not only that cerebellum but also the areas of abnormal enhancement was seen in the left temporal parankaima. So it was a multi-centric disease now and it has increased a lot. Spectroscopy now clearly you see here the double peak sign. You see lipid lactate 0.9 to 1.3 ppm. You see your high choline going much above the creatinine NA reduced. So a typical spectrum of a neoplastic process and we know twin peak double peak is very typical with lymphomas. This is our ASL non-contrast perfusion. We did contrast non-contrast perfusion both. The processed images are not in the packs but you can see that these areas were hyper perfused. So all this which is appearing little hyper intense on ASL that corresponds to the area of hyper perfusion. So now we were completely thinking in terms of neoplastic process and what we were thinking in terms was lymphoma. So as I told these are the two companion cases. So this also turned out to be lymphoma on subsequent biopsy but what happened in between just to bring one more important point for lymphoma patients. Somebody this patient had a tendency to go to multiple doctors. So he went to some other neurosurgeon and somewhere he received steroids as a part of his treatment and drastically the lesions they vanished. So this is what has to be taken care of. So this is May 2017. So that was April and this is May. In one month it appeared as if everything has cleared off and the patient will be kind of improving now. So this is the mistake many a times happens in the course of lymphoma diagnosis. Always make a point if you are thinking of lymphoma the tissue sampling has to be done pre steroid because steroid can change the radiology and steroid can change the histopathology as well. Both can be changed. So this was our pre biopsy planning scan the surgeon thought that let's do a scan before doing a biopsy so that they know where to go in and to our surprise there was nothing much to biopsy right now. So this was thought that after our discussion that still we think it is lymphoma let's wait stop the steroid wait and then go ahead. And that is what it was done. And I just kept one sequence see the relapse new lesion a big one in the left hallemas lot of perillational edema mass effect and the patient kept on well for this entire period of time. Old age gentlemen imbalance little bedridden sort of this was biopsy and turned out to be lymphoma and then was treated. So this is the highlight I wanted to bring in that lymphoma can present with multiple cranial nerve enhancement and thickening and don't give steroid before you biopsy or do your histopathology. So coming to discussion both these cases we have published one was published in conjunction with the NT team at our hospital as primary lymphoma of the internal acoustic neatus mimicking vestibular sonoma the one which we discussed the old man. And this is not our article this has been published from JJ medical college on multiple hypertrophic relapsing remitting cranial neuropathies as an initial presentation of primary CNS lymphoma this is very important. And we have put in for publication and it is just online available now for our six cases of abnormal cranial nerve enhancement turning out to be lymphoma and what are the differentials of this kind of a pattern just to revise. One is lymphoma one is the other ones are neuro sarcoidosis a myeloid neuropathy neurocephalus acute and chronic inflammatory demyelinating polyneuropathy like GBS CITP and neurofibromatosis NF1 so for our exam going residents these are the differential for multiple cranial nerve enhancement and thickening. The degree of cranial nerve enhancement smooth versus irregular nerve enlargement and the presence or absence of left to manager disease helps in differentiating the differential primary CNS lymphoma presenting as multiple cranial nerve thickening is a rare clinical entity. It has imaging feature presentation typically in the form of white matter or basal ganglia lesion in contact with the CSF surface as what we saw. These may present as hyper dense area of masses on an enhanced CT scan so we know because lymphomas are cellular tumors therefore they are T2 hyper intense they show restricted diffusion and they are hyper dense on plain CT. And as areas of altered signal intensity on MRI with solid enhancement in immunocompetence and ring enhancement in immunocompromised which happens with the steroid as well with or without areas of hemorrhaging areas or necrosis. So dear friends with this I come to conclusion of this radiology journal club session for today on neuro radiology. We discussed two articles and then we discussed two cases and try to bring in the important highlights out of all these. Thanking bears once again and to all of you who are still there I would request you to give your feedback in the chat box kept one small poll if you could please spare a few minutes and participate is the idea of radiology journal club worth going ahead with so you have your options yes no and I don't know so just choose one of them. So that we know where to move ahead with. So I think you have your options on the screen. So you can choose one of them. So I can see the answers coming up in the chat box and people are saying yes. So great. The next question is, would you like to present article if you decided like ahead of time that this is the article we are going to discuss and would you like to present one article in the journal club. So two people are saying yes in the polling options. And I think in the chat box so that can be something which we can actually do we can announce the article a week ahead or two weeks ahead and even decide who will present it. And then we can discuss in that way. Next is should we add interactive case discussion means can we do it like in a vibe up kind of a thing that one of you unmute and talk about it. So do you think we should go ahead with that plan. Yes, not dead or discuss case but don't make it like a Viva so don't kind of unmute someone and take it like a Viva so few people think that we should do it like a Viva but it's like a divided opinion so let's think about it. And next is, would you like to get your cases discussed with the experts so that is one idea that you can actually share on the Google Drive say two weeks ahead with history. Our experts will go through the cases and then we will all discuss together so here are most of you want this to happen. So okay so let's think of transforming the upcoming journal clubs, stay tuned, because many other things are also in pipeline masterclass on a musculoskeletal topics and definitely these Thank you for all sparing your time on the Sunday morning. And with this, I would like to conclude the session for today. Patkasa would you like to add any idea. No, I'm fine. I'm fine. Thank you for doing this. Thank you, Gauri. Please conclude the session now. Thank you for conducting it beautifully as always a new concept put together by Shilpa ma'am Patkasa the entire Indian radiologist team obviously Dr. Muthusha and it's a pleasure to be a part of this team, and especially Mamda who's been helping us throughout all the events that we've been planning so far and we'll be planning in the future. And I'm sure a lot of people are giving a lot of positive response and you've received some good yeses to interactive case discussions and people wanting to participate in the further sessions. So we'll definitely keep that in mind. And I would like everyone to please go ahead and register for our CT bars and the MSK imaging masterclass that's coming up also for the radiology clubs which we plan in the future the next one will be in October for breast imaging, which will be mentored by Dr. Shilpa Lard. So yeah that's about it. Thank you so much for joining us. Thanks Muthusha. Thank you Patkasa. So would you like to say anything. No I'm fine. Thank you Gauri. Thank you. Thank you everyone and see you next month.