Scielo RSS <![CDATA[SA Journal of Radiology ]]> vol. 23 num. 1 lang. en <![CDATA[SciELO Logo]]> <![CDATA[<b>Solid to cystic: A case report of imaging findings of atypical lung metastases</b>]]> The imaging spectrum of pulmonary metastases varies greatly, with solid and partly cavitating nodules being the most common. When imaging the oncology patient, specifically follow-up imaging post-treatment, the radiological aim is to assess for disease regression and thus treatment response, usually with resolution of these nodules. We report an interesting case series of a patient with primary endometrial carcinoma presenting with pulmonary metastases. This imaging series eloquently depicts the temporal evolution of the metastatic solid pulmonary nodules to cavitating nodules and finally to thin-walled cysts. Baseline imaging in this scenario is vital to exclude pre-existing cystic lung disease. The progression of solid pulmonary metastases to simple cysts is an uncommon therapy-related consequence, but an important entity to recognise, not only as an indicator of good treatment response, but also to evaluate for potential life-threatening complications such as spontaneous pneumothoraces. <![CDATA[<b>Embryonal rhabdomyosarcoma of the biliary tree in a paediatric patient - A rare cause of obstructive jaundice</b>]]> Rhabdomyosarcoma (RMS) is the most common soft-tissue sarcoma in the paediatric age group, ranking fourth in frequency after central nervous system tumours, neuroblastomas and nephroblastomas. Embryonal RMS of the biliary tree is considered a rare entity, with the most common clinical presentation being that of obstructive jaundice. We present the case of a 4-year-old boy who presented with hepatomegaly and obstructive jaundice. Biochemically, there was evidence of elevated ductal enzymes with conjugated hyperbilirubinaemia. The magnetic resonance imaging (MRI) features were consistent with a biliary RMS with the differential diagnosis of a choledochal cyst initially included based on the computed tomography images. The diagnosis of embryonal biliary RMS was later confirmed on histology. This case illustrates the importance of considering malignant aetiologies in paediatric cases of obstructive jaundice, as this entity is infrequently described in the literature and may mimic the appearance of a choledochal cyst. The demonstration of enhancement of intraductal material within the biliary tree on MRI and the presence of arterial waveforms within the intraductal mass on ultrasound assists in the differentiation between biliary RMS and a choledochal cyst. <![CDATA[<b>Cost analysis of violence-related medical imaging in a Free State tertiary trauma unit</b>]]> BACKGROUND: Violence is a leading public health problem worldwide. Beyond the pain and suffering, violence has a significant economic impact on a country's health, policing and judicial services. Because of the lack of current and comprehensive data in South Africa, local violence-related economic impact studies are largely estimations. Violence-related imaging expenditure, as a component of a public hospital's expenditure, is yet to be determined. OBJECTIVES: The goals of this study were to measure the violence-related patient burden on Pelonomi Tertiary Hospital's (PTH) trauma and radiology services, determine the imaging-component cost of violence-related injuries and calculate the financial burden violence has on the hospital's expenditures. METHOD: From the PTH's trauma unit patient registry, 1380 patients with violence-related injuries were consecutively sampled for 6 months ending 31 December 2017. Imaging investigations were documented and categorised according to the South African National Department of Health's 2017 Uniform Patient Fee Schedule (UPFS). Descriptive analysis and cost calculations were performed using the 2017 UPFS tariff schedule and hospital-specific health efficiency indicators - patient-day equivalent and expenditure per patient-day equivalent. RESULTS: Violence-related injuries accounted for 50.64% of all trauma department visits and received a total of 5475 imaging investigations. Violence-related imaging investigations represented 14.81% of all investigations performed by the radiology department in the study period. Overall violence-related admission costs amounted to R35 410 241.85 (8.33% of the hospital's total expenditure), of which 20.08% (R7 108 845.00) was attributed to imaging investigations. CONCLUSION: Violence-related admissions had a high patient and financial burden on PTH. The pinnacle of healthcare cost saving is violence prevention; however, the cost-conscious radiologist could assist with cost saving if responsible and ethical imaging practices are followed. <![CDATA[<b>Outcomes of prostate artery embolisation for benign prostatic hyperplasia in 10 cases at Steve Biko Academic Hospital</b>]]> BACKGROUND: Benign prostate hyperplasia (BPH) remains a common cause of lower urinary tract symptoms (LUTS) in ageing men in South Africa and can impact significantly on the quality of life (QOL) of these patients. The Urology Department at Steve Biko Academic Hospital (SBAH) can generally only offer men with LUTS the following treatment options: watchful waiting, medical treatment and surgical management. In men with symptomatic BPH, who are refractory to medical treatment, where anaesthesia is contra-indicated because of co-morbidities or transurethral resection of the prostate (TURP) is contra-indicated because of the prostate size, the Urology and Radiology departments at SBAH recently introduced prostate artery embolisation (PAE). AIM: To assess the outcome of PAE in 10 men with LUTS, secondary to BPH, by comparing their urinary symptoms, QOL and prostate volume before and 3 months after they underwent PAE in the Radiology Department at SBAH. METHOD: The review included the first 10 men who had undergone therapeutic PAE for symptomatic BPH from May 2016 to September 2016. The subjective symptomatic feedback was assessed according to the International Prostate Symptom Score (IPSS) and the Global Quality of Life questionnaire, created by the American Urological Association (AUA). The reduction in the size of the prostate was measured on magnetic resonance imaging (MRI). RESULTS: Embolisation was technically achieved in all 10 patients. Bilateral embolisation was performed on nine patients. One patient received unilateral embolisation secondary to unilateral tortuous and atherosclerotic changes of the iliac arteries. Within the 3-month follow-up, the mean IPSS score improved by 15.7 points (p < 0.0039), the mean QOL improved by 4.1 points (p < 0.0039) and the mean prostate volume reduction was 21.8 mL (p < 0.0039). Despite improvements observed, there was one clinical failure. No major complications were reported that increased hospital stay, required hospital readmission or required surgery. CONCLUSION: The study on the first 10 PAE performed in SBAH concludes that PAE is a safe and effective procedure with favourable short-term follow-up results. This indicates that PAE can safely be offered to patients, who are refractory to medical treatment and not suitable candidates for surgery, in urology departments such as in SBAH. <![CDATA[<b>Prevalence and pattern of basal skull fracture in head injury patients in an academic hospital</b>]]> BACKGROUND: Basal skull fractures (BSFs) have been reported to be a major cause of morbidity and mortality in the literature, particularly in young male patients. However, there are limited data available on the aetiology, prevalence and patterns of such observed in South AfricaOBJECTIVES: To evaluate the prevalence and pattern of BSF in head injury patients referred to Dr George Mukhari Academic Hospital, Gauteng, South Africa.METHODS: Patients of all ages with head injuries were considered for the study, and those who met the inclusion criteria were scanned using a 128-slice multidetector helical computed tomography (CT) machine after obtaining consent. Data were prospectively obtained over a 6-month period, interpreted on an advanced workstation by two readers and statistically analysed.RESULTS: The prevalence of BSF in this study was found to be 15.2%. The majority of patients (80.5%) were under 40 years old, with a male to female ratio of 3:1. The most common aetiology of BSF was assault, which accounted for 46% of cases. The middle cranial fossa was the most frequently fractured compartment, while the petrous bone was the most commonly fractured bone. There was a statistically significant association between head injury severity and BSF, and between the number of fracture lines and associated signs of BSF (p < 0.001). The sensitivity of clinical signs in predicting BSF was 31%, while specificity was 89.3% (p = 0.004).CONCLUSION: The prevalence and pattern of BSF found were consistent with data from previously published studies, although, dissimilarly, assault was found to be the most common aetiology in this study. <![CDATA[<b>Vanishing white matter disease imaged over 3 years</b>]]> Childhood ataxia and central nervous system hypomyelination (CACH), also known as 'vanishing white matter disease' (VWM), is a leukoencephalopathy with autosomal recessive inheritance. It is characterised by normal psychomotor development initially, with an onset of neurological deterioration that follows a chronic and progressive course. Stress conditions such as febrile infections, minor head trauma or even acute fright provoke major episodes of neurological deterioration. We present a case of a 2-year-old child who presented with spasticity and cerebellar ataxia. After magnetic resonance imaging (MRI) of the brain, CACH/VWM was diagnosed on the basis of the typical clinical and MRI findings. As there is no known cure for CACH/VWM, our patient was followed up over 3 years with MRIs of the brain to assess the progressive involvement of the cerebral white matter. In those patients with suggestive or inconclusive MRI findings for CACH/VWM, particularly in the presymptomatic stage and adult onset variants, involvement of the inner rim of the corpus callosum should prompt the inclusion of CACH/VWM in the differential diagnosis. Biochemical markers such as the asialotransferrin:transferrin ratio in the cerebrospinal fluid can also potentially be used as a screening tool in this subset of patients prior to gene mutation analysis. <![CDATA[<b>Atypical exophytic liver mass: Giant pedunculated hepatic haemangioma masquerading as a gastrointestinal stromal tumour of the gastric wall</b>]]> Haemangioma is the most common benign tumour of the liver. However, an exophytic hepatic haemangioma, especially the pedunculated form, is very rare. Giant pedunculated haemangiomas are prone to complications because of the narrow size of the pedicle. A large number of lesions can potentially present as exophytic liver masses, and accurate diagnosis can sometimes be challenging. We report a case of an incidentally discovered asymptomatic giant pedunculated liver haemangioma in the region of the lesser sac in a prospective renal donor, which was initially suspected to be a gastrointestinal stromal tumour of the stomach wall. Multiphasic computed tomography and confirmatory magnetic resonance imaging scans ultimately revealed the true nature of the lesion, which turned out to be an exophytic pedunculated hepatic haemangioma from the left lobe of the liver. The lesion was then surgically resected and histopathologically confirmed to be a haemangioma. The patient subsequently underwent successful renal donation as planned. Being a benign lesion with characteristic imaging features, accurate radiological diagnosis is absolutely essential for the appropriate management of such atypical haemangiomas. <![CDATA[<b>Medical doctors' awareness of radiation exposure in diagnostic radiology investigations in a South African academic institution</b>]]> BACKGROUND: Diagnostic investigations using radiation have become a critical feature of medical practice in recent times. However, the possibility of doctors' underestimation of risks of over-exposure of patients to diagnostic radiation still warrants further evaluation. OBJECTIVES: To investigate doctors' awareness of diagnostic radiation exposure at Dr George Mukhari Academic Hospital, South Africa METHODS: This was a cross-sectional, analytical investigation of the awareness of doctors about radiation exposure in diagnostic radiology investigations. A cluster sampling technique was employed to recruit 217 participants. Consent and approval of the participants were sought and obtained before questionnaire administration during departmental meetings between October 2017 and March 2018. RESULTS: Of the participants, 80% had no formal training on radiation exposure and 33.8% of them correctly estimated natural background radiation. Correct estimates of the effective dose from a single-view abdominal X-ray (AXR) were expressed by 7.5%, quantity of radiation of a single-phase computed tomography (CT) abdomen by 30.3% and dosage from a two-view unilateral mammogram by 29.1% of the participants. More than 75% of participants agreed that children are more sensitive to radiation, but only 10.5% suggested medical termination of pregnancy for a woman who had CT abdomen and pelvis with contrast. Dosage and risk of inducing fatal cancer from common but more complex imaging procedures were poorly understood. Only the doctors of the radiology department showed a statistically significant (p < 0.0001) association with regards to their radiation awareness. CONCLUSION: Because of the high rate of poor awareness of radiation risks observed in this study, it is important to initiate, early in the medical curriculum for medical students, the need for a rotation in the Department of Radiology, similar to such rotations in other medical specialties. <![CDATA[<b>Multicentre study on dynamic contrast computed tomography findings of focal liver lesions with clinical and histological correlation</b>]]> BACKGROUND: Current advancements in dynamic contrast imaging of the liver have enabled increased sensitivity in the diagnosis of liver lesions. Evaluation and characterisation of the enhancement pattern of liver lesions in respect to the liver parenchyma aids in making a specific diagnosis. OBJECTIVES: The aim of this study was to determine the liver findings on dynamic contrast computed tomography (CT) scanning and correlate them with clinicopathologic findings. METHODS: This prospective cross-sectional study included 61 patients and took place between August 2017 and February 2018. Dynamic contrast CT was performed and the images were evaluated by two experienced radiologists. Correlation of the CT findings with histology results from an ultrasound-guided biopsy was done. Data analysis was performed using SPSS version 20.0. RESULTS: Hepatocellular carcinoma (HCC) was the most common malignant lesion seen and showed three patterns of enhancement: homogenous, abnormal internal vessels and heterogeneous enhancement. Abnormal internal vessel pattern was most specific (90.6%) and showed a high positive predictive value (PPV) of 78.6%. Rapid washout showed a specificity of 87.5% and a PPV of 72.2% in the diagnosis of HCC. Dynamic contrast CT scan had a sensitivity of 93%, specificity of 50%, PPV of 91% and diagnostic accuracy of 95.5% in differentiation of benign and malignant liver lesions. Considering only Liver Imaging Reporting and Data System (LI-RADS) category 5 as conclusive for HCC diagnosis, our study did not miss a significant number of HCCs. Liver Imaging Reporting and Data System category 5 showed specificity of 81.3% and PPV of 75%. CONCLUSION: Enhancement patterns on a dynamic contrast CT scan of the liver are useful in the interpretation of CT images for specific diagnoses. <![CDATA[<b>Cystic pelvi-abdominal mass in pregnancy: An uncommon presentation of a subserosal leiomyoma</b>]]> Uterine leiomyomas are common benign neoplasms. While generally easily diagnosed, variations in size and type of degeneration can drastically alter the imaging findings and result in diagnostic uncertainty. We present the case of a 34-year-old female with a large, cystic, pelvi-abdominal mass that was discovered in advanced pregnancy and misdiagnosed as an ovarian tumour. Intra-uterine demise of a viable foetus during an induction of labour and clinical deterioration necessitated further imaging and emergent surgical intervention. Further imaging, intra-operative findings and histopathological correlation revealed a pedunculated uterine leiomyoma with hyaline degeneration and areas of necrosis, complicated by left ovarian vein thrombosis. In addition to the intra-uterine demise, the unfortunate outcome included a total abdominal hysterectomy and unilateral salpingo-oophorectomy in a young patient. Typical leiomyomas are easily detected with imaging, however the varied clinical presentation and imaging findings in degenerating leiomyomas can prove a diagnostic challenge. This case describes a rare manifestation of a common condition and its subsequent diagnostic dilemma resulting in dire foeto-maternal outcomes. <![CDATA[<b>Renal arteriovenous malformation: An unusual pathology</b>]]> Renal arteriovenous malformations are rare renal vascular abnormalities. More commonly, the term refers to the congenital type of malformation. Only a few cases have ever been presented and reported in the literature, mostly with a nidus. We present the clinical, ultrasound and computed tomography findings and discuss the management related to a 63-year-old male with a right congenital renal arteriovenous malformation without a nidus that was successfully managed with coil embolisation. Relevant literature is hereby reviewed to highlight characteristic imaging and appropriate treatment.