Objective: The optic nerves are covered by the meningeal sheath and the nerve is surrounded by the fluid which communicates with the CSF space intracranially. Any variations in the CSF pressure can alter the perioptic space fluid and cause pressure effects on the optic nerve head. The optic disc does not possess cells of muller which hold nerve fibers together unlike other retinal cells, and hence swells up easily with increasing CSF pressure resulting in papilledema. Conversely, a decrease in intracranial pressure can cause perioptic space to collapse. Our aim in this exhibit is to present the normal appearance of the perioptic space on MRI, normal optic nerve sheath diameter, our institutional MRI protocol for optic nerve/ perioptic space evaluation, pathologies that cause changes in the perioptic space, and how perioptic space variations can be a clue to look for pathologies. Learning points: Our exhibit includes: Our institutional protocol for evaluation of the perioptic space and the optic nerve Normal appearance of perioptic space on different MRI sequences including high resolution T2W coronal, T2W axial and BFFE sequences Interesting case reports with altered perioptic space fluid including 1. Idiopatic intracranial hypertension 2. Shunt malfunction 3. Shunt over drainage 4. An interesting case of pseudotumor progressing to intracranial hypotension 5. Foster Kennedy syndrome 6. Intracranial hypotension 7. Differentiation of papilledema versus drusen The importance of looking at perioptic space and how it gives clue to the underlying pathology Associated findings to be evaluated on MRI Discussion: Perioptic spaces can give a clue to underlying intracranial pathologies. It is imperative for the radiologists to carefully evaluate the perioptic spaces and to look for additional findings if there is a variation. If there is dilatation of the perioptic space, it is important to look at the additional features including tortuosity of the optic nerves, protrusion of the optic disc, partial empty sella, enlarged meckel’s cave and bilateral transverse sinuses for stenosis. When there is collapse of the peri-optic space, other associated findings should be looked at including pachymeningeal enhancement, venous distention sign, cerebral edema, tonsillar ectopia, and other quantitative features like mamillopontine distance. Also, it is important to evaluate for tumors which can also result either in perioptic space distention or collapse. Read More

Meeting name: SPR 2023 Annual Meeting & Postgraduate Course , 2023

Authors: Jaganathan Sriram, Krishnan Venkatram, Jayappa Sateesh, Murphy Janice, Phillips Paul, Ramakrishnaiah Raghu, Charles Glasier, Choudhary Arabinda

Keywords: Perioptic space, distention and collapse, intracranial CSF pressure changes

Caudal regression syndrome (CRS) refers to a rare disorder with varying degrees of agenesis or malformations of the lower thoracic, lumbar, and sacral spine as well as the spinal cord with varying clinico-radiological features. Estimated incidence ranges from 5-10:100,000 births. Imaging is an integral part of the diagnosis and management of this condition. An extensive review of the imaging spectrum of CRS with several case-based examples would enable a complete understanding of the condition. We reviewed the imaging appearance of several cases of caudal regression, including in utero cases, from our tertiary care university based pediatric hospital. The various associated malformations, especially of the spinal cord, were examined in detail. We also analyzed the clinical symptomatology of these patients and correlated them with the imaging patterns. A detailed review of related literature was performed and consolidated information on the clinico-radiological spectrum of CRS was compiled. The following aspects of CRS have been discussed in detail: Predisposing maternal conditions and pathogenesis of CRS in the fetus. Pang groups 1 and 2 CRS and their imaging features. Renshaw types 1 to 4 sacral agenesis and their imaging features. Role of radiographs, ultrasound, and MRI in CRS. Spectrum of MRI features in the cord including shape of conus, level of termination, presence of cord tethering, associated neural tube defects and associated syrinx. Clinical manifestations of various types and their correlation with imaging features. Imaging features correlating with progressive versus static neurological deficits. Imaging features that could signal potential benefit from surgical treatments. Prenatal diagnosis of CRS on obstetric ultrasound and fetal MRI: Imaging patterns and importance of antenatal diagnosis. Associated anomalies and syndromes and necessary additional imaging in CRS cases. Pitfalls in imaging of CRS. A complete understanding of CRS including clinico-radiological correlation of symptomatology and imaging appearance in CRS would enable detailed and accurate reporting of these scans. In particular, identifying imaging features that correlate with progressive neurological deficits and those that may benefit from surgical intervention can significantly improve patient management. Read More

Meeting name: SPR 2023 Annual Meeting & Postgraduate Course , 2023

Authors: Krishnan Venkatram, Jaganathan Sriram, Murphy Janice, Choudhary Arabinda, Jayappa Sateesh, Rowell Amy, Charles Glasier, Ramakrishnaiah Raghu

Keywords: Spine, Spinal Cord, Congenital

Objectives: Acute appendicitis is one of the common emergent indications for imaging in the hospital setting. Though ultrasound and/or CT remains the primary imaging modality, MRI with rapid sequence imaging is also gaining credence at multiple pediatric institutions to replace CT or even replacing Ultrasound in specific settings, as the first line imaging modality. Our aim in this exhibit is to present our initial experience on implementation of a limited rapid sequence MRI appendix, at our tertiary care pediatric hospital, to evaluate for acute RLQ pain. We also detail the advantages of MRI over CT scan, pitfalls of MRI, the appearance of acute appendicitis and complications including perforation/ abscess, and other pathologies, which we found on MRI during the evaluation for acute abdominal pain. Learning points: Our exhibit includes: Role of MRI appendix – emerging as an alternative to CT in diagnostic dilemma and avoids radiation Logistics of setting up MRI appendix protocol and managing expectations Decision on when to use MRI for evaluation of suspected appendix Describe rapid sequence tailored protocol developed at our institution In the context of increasing supply chain disruption issues such as CT contrast shortage, the advantages and disadvantages of MRI Normal appearance of the appendix and peri-appendiceal region Classical appearances on MRI appendix 1. Acute Appendicitis 2. Inflammatory mass 3. Contained appendiceal perforation 4. Abscess 5. Identifying appendicolith 6. Perforated appendicitis with abscesses in extraperitoneal spaces Alternate pathologies which we may mimic appendicitis and was identified on MRI 1. Terminal ileitis 2. Colitis 3. Ovarian pathology Discussion: Acute appendicitis is one of the common pathologies encountered in pediatric emergency setting and needs prompt attention. Ultrasound is the cheapest and most easily available imaging modality, but is operator dependent, and may be limited by patient body habitus, and location of the appendix. MRI is emerging as an alternative to CT in the evaluation of appendicitis in the pediatric population. Our initial experience with implementation of the MRI appendix protocol is promising in terms of acceptance by the clinical teams, image resolution, diagnostic confidence, logistical support from the administrators, sensitivity and patient outcome. We had the added benefit of being able to utilize this protocol during CT service disruptions and contrast shortage. Read More

Meeting name: SPR 2023 Annual Meeting & Postgraduate Course , 2023

Authors: Jaganathan Sriram, Rowell Amy, Ali Sumera, Krishnan Venkatram, Jayappa Sateesh, Murphy Janice, Ramakrishnaiah Raghu, Wong Kevin, Schmitz Kelli, Choudhary Arabinda, Buchmann Robert

Keywords: MRI Appendix, Rapid sequence imaging, iodinated contrast shortage