2012 in review

The WordPress.com stats helper monkeys prepared a 2012 annual report for this blog.

Here’s an excerpt:

600 people reached the top of Mt. Everest in 2012. This blog got about 9,100 views in 2012. If every person who reached the top of Mt. Everest viewed this blog, it would have taken 15 years to get that many views.

Click here to see the complete report.

Top 20 Facebook Applications in Science and Medicine

Dr Himadri S Das:

Interesting read…

Originally posted on ScienceRoll:

logo_facebook.jpgFacebook is a social networking site with several thousands of applications that you can add to your profile. While some of the biggest stories in the news are about the future of this community site, I thought I should create a collection of useful applications from the field of medicine, science and web 2.0. Enjoy!

  • : List your Medline-listed academic publications on your Facebook profile, and view your friends’ publications as well!

pubmed.jpg

  • : Use Med Tracker to share your ratings of prescription and over the counter drugs.

drugrating.jpg

  • : You can test your health knowledge with this interactive health quiz game. Challenge your friends to see who knows more about health and medicine. You start with being Pre-Med, then you can become Medical Student and maybe, the “Chief of Medicine.”

healia.png

  • : Every day that you click on the Donate button on the Red Cross toolbar, will donate money to the…

View original 657 more words

CDC Issues Recommendations on Use of New Treatment Option for Latent TB Infection « The Communicator

CDC Issues Recommendations on Use of New Treatment Option for Latent TB Infection « The Communicator:

‘via Blog this’

radiozenmatrix imaging

Japanese Encephalitis

JE

 

 

 

 

**Child with fever & altered sensorium with symptoms developing developing acutely

 

Japanese encephalitis is a disease caused by the mosquito-borne Japanese encephalitis virus. The Japanese encephalitis virus is a virus from the family Flaviviridae. Domestic pigs and wild birds are reservoirs of the virus; transmission to humans may cause severe symptoms. One of the most important vectors of this disease is the mosquito Culex tritaeniorhynchus. This disease is most prevalent in Southeast Asia and the Far East.

 

 

 

 

 

Japanese encephalitis has an incubation period of 5 to 15 days and the vast majority of infections are asymptomatic: only 1 in 250 infections develop into encephalitis.

 

Severe rigors mark the onset of this disease in humans. Fever, headache and malaise are other non-specific symptoms of this disease which may last for a period of between 1 and 6 days. Signs which develop during the acute encephalitic stage include neck rigidity, cachexia, hemiparesis, convulsions and a raised body temperature between 38 and 41 degrees Celsius. Mental retardation developed from this disease usually leads to coma. Mortality of this disease varies but is generally much higher in children. Transplacental spread has been noted. Life-long neurological defects such as deafness, emotional lability and hemiparesis may occur in those who have had central nervous system involvement. In known cases some effects also include nausea, headache, fever, vomiting and sometimes swelling of the testicles.

 

The causative agent Japanese encephalitis virus is an enveloped virus of the genus flavivirus and is closely related to the West Nile virus and St. Louis encephalitis virus. Japanese Encephalitis is diagnosed by detection of antibodies in serum and CSF (cerebrospinal fluid) by IgM capture ELISA.Infection with JEV confers life-long immunity. All current vaccines are based on the genotype III virus.

 

 

Japanese encephalitis (JE) is the leading cause of viral encephalitis in Asia, with 30,000–50,000 cases reported annually. Case-fatality rates range from 0.3% to 60% and depends on the population and on age. Rare outbreaks in U.S. territories in Western Pacific have occurred. The natural host of the Japanese encephalitis virus is bird, not human, and many believe the virus will therefore never be completely eliminated

 

radiozen
A Bold GNU Head


LIST OF OPEN SOURCE SOFTWARES


           Categories

        Public Health and Bio surveillance

Electronic health or medical record
  • CHITS Community Health Information Tracking System – EHR for public health community centres in developing countries
  • ClearHealth Clearhealth - Flexible and standards compliant EMR/EHR
  • ElementalClinic - open source web-based EMR for mental health written in Perl, licensed under the GPL. Also available as a hosted service.
  • FreeMedForms - open source (c++/Qt4.5) highly dynamic EMR. FreeMedForms is released under the BSD license and is intended to be fully internationalized.
  • GNUmed is a WxPython application that uses PostGreSQL.
  • FFEHR Free Feathers Electronic Health Record – EHR application developed using the Mozilla programming framework. FFEHR can run independently or within the Firefox browser.
  • HealthForge - a .Net e-health groupware solution with EMR, Practice Management and patient/physician connectivity. Built on the popular DotNetNuke framework.
  • Hospital OS Open source hospital information system in Thai
  • HOSxP
  • Indivo - open source, personally controlled health record system that enables patients to own complete, secure copies of their medical records. Powers the Dossia framework
  • Medical a multi-user, highly scalable, centralized Electronic Medical Record (EMR) and Hospital Information System (HIS) foropenERP
  • OpenEHR Inter-operable, implementation independent Health Record Specifications [1]
  • OpenEMR an open-source Electronic Medical Record (EMR) software.
  • Open Healthcare
  • OpenMRS is a community-developed, open-source, enterprise EMR framework. Extensible and scalable EMR based on Java.
  • OpenVista is a VistA-based distribution with a cross-platform, GTK/C# based clinical front-end. Both client and server are licensed under the AGPL. Reference deployments in a range of small and large facilities.
  • OSCAR McMaster an open-source Electronic Medical Record (EMR) software. The billing component of the software is specialized for the needs of the Canadian health care providers.
  • PatientOS a rich client open-source EMR designed to evolve to a healthcare information system.
  • SmartCare
  • Tolven Healthcare
  • TORCH - Easy to install and customize EMR application in Python
  • VistA — Veterans Administrations integrated Electronic Health Record and Electronic Image Record system available for non-governmental use on MUMPS licensed systems as WorldVistA.
  • ZEPRS The ZEPRS application is an electronic patient record system that enables clinicians to enter data from patient visits using a web browser.
  • Care2x Hospital information system/practice management system/EHR
  • ClearHealth ClearHealth covers the five major areas of practice operations including scheduling, billing, EMR, HIPAA Security and accounts receivable. It offers a fully comprehensive system which now offers tools like E-Prescribing, Drug Interactions, Electronic Labs and Lab ordering. It is the largest open source healthcare solution serving more than 500 sites including the Primary Care Coalition network in MD with 50 sites and around 100,000 patients.
  • FreeDiams - open source (c++/Qt4.5) prescriber and drugs interactions tester. FreeDiams is released under the BSD license and is intended to be fully internationalized but for now drugs database and interactions database are only available in french.
  • FreeMED is a practice management and electronic and computer records system. It allows the tracking of medical data, in detail, with preservation not just of the diagnosis but the reasons for medical encounters. FreeMED is released under the LGPL GNUlicense. FreeMED is an HIPAA compliant FOSS Practice Management System that handles billing.
  • MedinTux MedinTux is a French medical practice management system, with a web interface as well as a desktop one, that has been initially to manage a hospital emergency department. Being very modular, it has been extended to run also many different smaller practices. It works on GNU/LinuxMac OS XMicrosoft Windows
  • MirrorMed MirrorMed is a free and open source EHR and practice management system written in PHP. MirrorMed is a web-based application that is capable of running a healthcare practice. MirrorMed shares code with FreeMED, and OpenEMR. MirrorMed is primarily sponsored by SynSeer.
  • Office Manager Encompassing office management healthcare software for medical practices, doctors groups, DMEs, retailers, etc. It does User/patient management, point of sale, scheduling, sign-in, inventory, insurance claims, accounting, etc. Any OS!
  • Open Dental Dental practice management software wiki article Open dental
  • OpenEMR (see also the OpenEMR wikipedia article)
  • OpenTAPAS Technology Assisted Practice Application Suite (TAPAS) is a term that describes digital tools that assist physicians deliver care in a paper based office
  • Elexis Praxisprogramm is an Eclipse RCP program for all aspects of a medical practice: electronic medical record (EMR), laboratory findings etc., as well as accounting, billing (Swiss TARMED-System, other systems to be developed) and other daily work
  • DHIS Open-source district health management information system and data warehouse (license: BSD license)
  • iHRIS Suite Open source platform for management of human resources for health developed by IntraHealth International and funded by USAID (license: GPLv3)
  • 3D SlicerMedical Visualization and Processing Environment for Research
  • Amide tool for viewing, analyzing, and registering volumetric medical imaging data sets, actively being developed
  • BioImageXD software for analysis, processing and 3D rendering of multi dimensional, multi data channel, time series image data from microscopy and other sources
  • BrainStorm an electro/magnetoencephalography (EEG/MEG) data processing and vizualisation toolbox.
  • BrainVisa a brain imaging package including data processing and visualization capabilities, such as T1-based gyrus segmentation, diffusion-based fibertracking, PET, MEG, EEG and more.
  • CDMedic PACS
  • ClearCanvas Workstation is an open source DICOM workstation and application framework for developing medical imaging applications.
  • CTSIM Computed Tomography Simulator, active development
  • DCM4CHE Open Source Clinical Image and Object Management written in java
  • DCMTK is a collection of libraries and applications implementing large parts the DICOM standard
  • DeVIDE is the open source (BSD-style license) and cross-platform (Windows, Linux) Delft Visualization and Image processing Development Environment, a visual programming system focused on medical visualization and image processing. DeVIDE incorporates VTK, ITK, numpy, matplotlib, DCMTK and GDCM. Latest features include a visual DICOM browser.
  • Dicom4j An open source DICOM Java framework.
  • Dicom4j-apps Free and open-sources DICOM applications in Java.
  • DICOM Router a variety of DICOM related utilities
  • DICOM Validation Tool (DVT) is a software utility and a set of .NET components that will assist in testing the medical / healthcare protocol DICOM. DVT provides you the methods to transfer and validate DICOM objects.
  • Drishti is a volumetric visualisation package for viewing Computer Tomography data. Able to import DICOM image stacks.
  • ecg2png Program designed to convert scanned 12-lead electrocardiograms into PNG format
  • Endrov Image and data viewer and editor
  • Eviewbox Java medical imaging software
  • GDCM Grassroots DiCoM is a C++ library for DICOM medical files. It is automatically wrapped to python/C#/Java (using swig). It supports RAW,JPEG (lossy/lossless), J2K,JPEG-LS,RLE and deflated. It also comes with DICOM Part 3,6 & 7 of the standard as XML files.
  • Imlib3d C++ library for 3D (volumetric) image processing
  • ITK Segmentation and Registration Toolkit
  • ITK-SNAP Interactive software for 3D image navigation, annotation and automatic segmentation
  • kradview Free (GPL) DICOM viewer, for Linux and FreeBSD.
  • METK is an open source toolkit to visualize and explore medical datasets.
  • Miniwebpacs storage, control and recovery of medical images and information in healthcare providers of small and medium capacity. Such system is based on the DICOM standard and in the actual WEB technologies.
  • MITK Medical Imaging Interaction Toolkit
  • NIRFAST NIRFAST is an open source FEM based software package designed for modeling Near Infrared Frequency domain light transport in tissue.
  • O3-RWS is the Radiology Workstation of the Open Three ( O3 ) Consortium. According to the IHE definitions, O3-RWS is an Open Source, DICOM based, Internationalized, Modular and Portable Image Display actor plus the integration of several other IHE actors.
  • OsiriX - [3] 3D DICOM Medical Viewer for Mac OS X. Complete DICOM Viewer with DICOM network support
  • Ogles is a three-dimensional volume and slice data visualization tool
  • Opensource PACS Wet Read system includes: image order, image reconciler, radiologist workstation (DICOM viewer), DICOM structured reporting, web-based summary of patient diagnosis. (see Projects under Navigation box)
  • ParaView Large Scale Visualization tool
  • PhP Nuke healthcare PHP-Nuke based system for Health Institutes. X-Ray and Register modules for storing patient data with pictures. System is DICOM compatible
  • Tempo(Topographic Eeg Mapping PrOgram) is open source software for 3D visualization of brain electrical activity
  • Virtual PACS allows radiologists to use a DICOM workstation to access multiple DICOM repositories as a single federated virtualized PACS. The DICOM repositories are exposed on caGrid and can include PACS, image archives such as National Cancer Imaging Archive or other DICOM data warehouses.
  • Voreen stands for Volume Rendering Engine. It is a library providing essential functionality for visually exploring volume data sets. Voreen supports most relevant data formats as for instance DICOM and is currently used in medical visualization as well as for visualizing electron microscopy data.
  • VTK Visualization Toolkit
  • Xebra (medical imaging software)
  • Blood_collection is a Web based software to increase the number of donors in blood collections by managing slots for registrations, with a front-end to delegate the blood collection creation and administration (license: GPL)
  • Caisis is a web based information system for the storage and analysis of cancer patient data intended to bridge the gap between clinic and research (license: GPL)
  • OpenClinica is a web-based application that facilitates electronic data capture in clinical trials. The system is free but commercial support is available (license: LGPL)
  • Open Infrastructure for Outcomes (OIO) system enables clinicians, researchers, and other non-programmers to create and maintain flexible and portable patient/research records
  • OpenMEDIS is a simple, flexible, and standardized Web based tool to collect and process information on health technology infrastructure in low- and middle income countries (license: GPL)
  • Resmedicinae Open source medical information system for GPs (license: GPL)
  • trilonis-mc For managed healthcare group eligibility, billing, capitation, and claims adjudication. Aimed at TPAs, HMOs, PPOs, and self-insured employers. HIPAA compliant. Will handle medical, dental, vision, psych, section 125 and COBRA (license: GPL)
  • Mural Project The Open Source Mural Project from Sun is a robust Master Index. It can be configured as a Master Patient Index, Master Provider Index, or any other Index. Fully extensible and configurable. Many existing installations prove scalability and functionality. By making use of the available PIX/PDQ implementation (http://kenai.com/projects/healthcaresolutions), it is IHE Comliant. Commercial licensing and support are available.
  • HAPI (HL7 application programming interface; pronounced “happy”) is an open-source, object-oriented HL7 2.x parser for Java
  • nHAPI .Net version of HAPI (http://hl7api.sourceforge.net/)
  • HL7 Inspector 2 HL7 analysis and validation tool
  • O3-DPACS stands for “Open Three ( O3 ) – Data & Picture Archiving and Communication System”. O3-DPACS is a DICOM & HL7 based IHE compliant Open Source PACS extended to any type of data
  • Open LIS-HL7 HL7 library written in Delphi 6, last updated in 2002
  • ProtoGen/HL7 an implementation of HL7 in C++, last updated in 2001
  • hl7lib Software implementing Health Level 7 protocols commonly used in the medical industry, last released in the year 2000
  • HL7ImExa is table driven set C routines to encode/decode HL-7 messages, last updated in 1996
  • BioSig library for biomedical signal processing featuring, for example, the analysis of biosignals such as the electroencephalogram (EEG), electrocorticogram (ECoG), electrocardiogram (ECG), electrooculogram (EOG), electromyogram (EMG), respiration, and so on License: GPL
  • ecg2png Program designed to convert scanned 12-lead electrocardiograms into PNG format
  • BioMail is a small web-based application for medical researchers, biologists, and anyone who wants to know the latest information about a disease or a biological phenomenon. It is written to automate searching for recent scientific papers in thePubMed Medline database
  • caGrid is an underlying service oriented infrastructure that supports caBIG, an initiative of the National Cancer Institute
  • Jumper 2.0 is a Science 2.0 technology that uses knowledge tags to capture knowledge about data in remote data stores. It collects these in tag profiles that are stored in a Knowledge base and search engine.
  • MIX Meta Analysis software for Excel
  • OpenClinica is a web-based platform for managing clinical studies, created by Akaza Research. Key functions include EDC, CRF, protocol, and site management.
  • BioLinux
  • Chiapas is a data translation package that handles mapping, encoding and decoding data between ANSI X12 4010A1 HIPAA data files and a variety of text, file, and database data sources. It works as a C#/.NET project add-in or a standalone clearinghouse.
  • GlassFish ESB Robust open source, light weight integration engine making use of JSR-208 (JBI). Full HL7 V2 and V3 support. Many transport protocols supported including Web Services, HL7 MLLP, TCP/IP, file, batch, etc.
  • Mirth is an open source cross-platform interface engine that enables bi-directional sending of HL7, NCPDP, X12 and DICOM messages between systems and applications over multiple transports. It has data translation capabilities between a large number of formats including database, XML, file, HL7 2.x, and HL7 3.
  • Bots Bots open source EDI translator. Any-to any-translations. Supported data formats: hl7 version 3, edifact, XML, X12, SAP idoc, flat-file, JSON. HL7 version 2 is in development.
  • CommCare an application of JavaROSA to support community health workers to plan their day, manage household visits, and report their data. Jointly developed by many organizations including D-tree International, Dimagi, and theUniversity ofWashington.
  • Epihandy Handheld survey/data collection application
  • The EpiSurveyor Project Handheld survey/data collection application
  • FrontlineSMS enables users to send and receive text messages with large groups of people through mobile phones.
  • Gather AED-Satellife standards-based application for data collection and reporting, with pluggable and interchangeable components/modules for data entry from a full range of wired and mobile computing devices
  • InSTEDD Several unique open-source tools for group-based SMS communication, assisted collaboration, real-time analytics, and mesh synchronization based on mobile technologies
  • JavaROSA open-source J2ME platform for data collection and decision support on mobile devices (used by Episurveyor, Epihandy, GATHER, and CommCare listed below)
  • MobilizeMRS Software that enables health workers to utilize electronic medical records remotely via SMS (using OpenMRS).
  • Mobilisr open source enterprise class mobile messaging platform – used in outreach campaigns for HIV
  • MoCa MoCa is a remote medical diagnostics platform for health workers in developing nations.
  • National Heart and Lung Institute medical software for handhelds
  • RapidSMS RapidSMS is a communications platform for coordinating SMS, voice messages, IVR menus, and email with user and group management – developed by UNICEF
  • Ushahidi Allows people to submit crisis information through text messaging using a mobile phone, email or web form. Displays information in map view.
  • GlassFish ESB Robust open source, light weight integration engine making use of JSR-208 (JBI). Full HL7 V2 and V3 support. Many transport protocols supported including Web Services, HL7 MLLP, TCP/IP, file, batch, etc.
  • Jengine apparently dead integration engine project written in java
  • Mirth is an open source cross-platform HL7 interface engine that enables bi-directional sending of HL7 messages[1] between systems and applications over multiple transports.
  • i2b2 - open source, web services framework designed to provide an integrated, intelligent search engine across many different clinical databases (conceptually termed the ‘Clinical Research Chart’ by the developers). Consists of a server ‘Hive’ (loosely coupled functional/messaging units) and a client interface (Eclipse-based or web-based).
  • OpenGalen computer-based multilingual coding system for medicine
  • [4] NHS Common User Interface (CUI) Programme. This enables a common look and feel across the five regions of the NHS as prescribed within the NHS plan.
  • ODIN Object-oriented Development Interface for NMR (Nuclear Magnetic Resonance)
  • ICD National Center for Health Statistics Classification of Diseases and Functioning&Disabilities
  • LOINC Logical Observation Identifiers Names and Codes – database of codes and universal identifiers for laboratory and other clinical observations
  • The National Drug Code Directory National Drug Code Directory
  • IPath open source telemedicine platform
  • ZephyrOpen Open source SDK for Health Monitoring Devices, like Heart rate monitor
  • IHEOS implementation of IHE (Integrating the Healthcare Environment) actors. IHE defines profiles for the use of various standards in the healthcare environment
  • GELLO - GELLO is the ANSI-accredited standard, HL7 Guideline Expression Language, Object Oriented. Gello.org is an effort to build open source authoring tool for creating GELLO expressions for multiple uses – including decision support, drug prior authorization, matching patients to clinical trials, etc.
  • MARiS Project The MARiS Project goal is to realize a package suite for Radiological Workflow using Open Source tools and technologies in according with IHE guidelines. The architecture of the single packages is based on the concept of IHE actor: this is very useful to develop a system that is an ensemble of single pieces that cooperate together using IHE profiles.
  • Mural Project The Open Source Mural Project from Sun is a robust Master Index. It can be configured as a Master Patient Index, and using the available PIX/PDQ implementation (http://kenai.com/projects/healthcaresolutions), it is IHE Comliant
  • HIEOS HIEOS is an open source implementation of IHE Cross Enterprise Document Sharing (XDS.b) and the Cross Community Access (XCA) integration profiles. The HIEOS platform enables secure health information exchange between various health communities, thereby enabling care providers to have longitudinal perspectives of patients’ health records.
  • The Integrating the Healthcare Enterprise (IHE) has developed a range of open-source interoperability testing tools called MESA, KUDU and its next generation tool GAZELLE to test healthcare interoperability according to the standards profiled by IHE in its technical Frameworks (See below Interoperability testing).
  • Tapeworm Gnome-desktop health profiler to keep track of your diet, including calories and %’s of fat, carbs, and protein, exercise, blood glucose, weight, etc…
  • OpenHRE(tm) Browsersoft Inc. OpenHRE Tool Kit – Proven and scalable platform for establishing Health Information Exchanges and deriving Meaningful Use of collected data. Includes Patient Locater Service/MPI, Record Exchange Service, Authentication and Access Control Service and Business Intelligence capabilities. Used to deploy and demonstrate a Nationwide Health Information Network Prototype. Used to deploy working Health Information Exchanges for State, Metropolitan and Rural intiatives.
  • ActiveHealth Open HIE API – example programs for building industry standard HIE web services interfaces to the ActiveHealth platform clinical intelligence services which include the CareEngine advanced clinical decision support, ActivePHR personal health record/health risk assessment, ActiveAdvice care management desktop, and performance measures.
  • RetroGuide epxress – a tool for EHR data analysis (quality improvement, decision support, research) based on workflow technology.
  • Lamdi Linux Anesthesia Modular Devices Interface
  • Physioneta collection of software for
    • WFDB Software for viewing, analyzing, and creating recordings of physiologic signals
    • record an application for capturing data from an HP CMS (Merlin) monitor
    • apdet Hilbert Transform based Sleep Apnea Detection using a Single Lead Electrocardiogram
    • ecgwave QRS detection and waveform boundary recognition using ecgpuwave
    • edr Derive a respiration signal from one or more ECG signals
    • puka software for detection of breaths in strain gauge recordings
    • many more components available in the Physionet Software Index
  • Medical Algorithms Project Not really software or strictly open source but usable medical algorithms nonetheless
  • HL7 Message browser and radiological image distribution. Last build was in 2003
  • MedMapper Medical decision making algorithm tool. Visual design tool generates Tcl/Tk code. Non-programmers can design interactive algorithms. Generates notes for inclusion in medical record. Runs freestanding or in Tcl Plugin.
  • OS-ELN Web based Electronic Lab Notebook
  • hxp Healthcare Xchange Protocol for interoperative communications. Data exchange/transfer, platform independent, XML-RPC, HL7, SOAP, EDIFACT. Not much activity since 2004.
  • OHF Eclipse foundation Healthcare project to create components to improve interoperability in the healthcare industry
  • Ideopass/ component to manage the identity of the patients in healthcare organizations
  • SQLCare is a clinical database/web application for healthcare providers in the United States
  • EGADSS is an open source tool that is designed to work in conjunction with primary care Electronic Medical Record (EMR) systems to provide patient specific point of care reminders in order to aid physicians provide high quality care
  • 03-MARIS HE compliant Department System IHE Order Filler and PPS Manager, for scheduling and workflow management in radiology department
  • 03-RWS IHE compliant Internationalized Modular Portable Radiology workstation
  • 03-TEBAN allows 3D reconstruction of brain electrical activity from magnetic resonance measurements (MRI) and brain activity mapping even in pathological patients.
  • 03-Fat Brother software for monitoring DICOM and HL7 services
  • 03-XDS is an XDS complete System
  • ROC.KIT This application allows for automated calculation of ROC curves (Receiver-Operating-Characteristic) from continuous medical data like laboratory results.
  • MyDrugRef is a social network of clinicians and pharmacists to improve prescribing. The project is based on Ruby on Rails.
  • Debian-Med largest Linux distribution for free medical software — welcomes requests for packaging based on a solid evaluation.
  • The Integrating the Healthcare Enterprise (IHE) has developed a range of open-source interoperability testing tools called MESA, KUDU and its next generation tool GAZELLE to test healthcare interoperability according to the standards profiled by IHE in its technical Frameworks. These tools are used by commercial and open source implementers. In particular they allow to prepare and perform conformance and interoperability testing at the IHE Connectathons, testing events regularly held around the world each involving over 100 systems.
  • The Certification Commission for Healthcare Information Technology (CCHIT) has developed an open-source program calledLaika to test EHR software for compliance with
  • CCHIT interoperability standards.
  1.                          Medical Practice Management Software                         Health System Management
  •                          Imaging/Visualization
  •                          Medical Information Systems
  •                          MPI – Master Patient Index
  •                          Standards Libraries
  •                                   Older Libraries
  •                          Signal Processing
  •                          Research
  •                          Operating System
  •                          Data Translation
  •                          Mobile / Handheld Devices
  •                          Integration
  •                          Coding
  •                          data related to the healthcare industry
  •                          Telemedicine
  •                          IHE
  •                          Private Health Record
  •                          Other
  •                          Out of the box distributions
  •                          Interoperability testing

   See also

Available categories:
There are other similar listings to which I referred to while creating this one. For details please see Further Sources at the end of this page.
Project attributes are listed in the following way:
<project name> [<used license> | <platform> | <client type>] – <project description>
<platform>: Lists all platforms on which the application can be installed and executed. In case of a client-server system that offers web-based access, this represents just the supported platform(s) for the server.
<client type>: Specifies the type of client. “native” means that you have to installed some sort of software on your local workstation to be able to access the application. “web-based” means that you can access the application via a Web browser.
<project description>: A short description of the project. Mostly this is just a copy & paste from the homepage of the project or from the related project page at sourceforge.net.

                   Billing

  • FreeB [GPL | unknown | unknown] – FreeB was the first GPL Medical Billing Engine. FreeB supports the HCFA 1500 and X12 837p 4010a formats. FreeB 2.0 (PHP) is developed by Uversa Inc. and SynSeer. FreeB 1.0 (Perl) is still used by the OpenEMRproject. FreeB 1.0 was rewritten as REMITT which is used by the FreeMED project.
  • Cancer Biomedical Informatics Grid™ – The National Cancer Institute (NCI) has launched the caBIG™ initiative to accelerate research discoveries and improve patient outcomes by linking researchers, physicians, and patients throughout the cancer community. The caBIG™ community has developed and released a variety of bioinformatics tools of which an overview is available here. For more details refer to the Open Source Project Site of the National Cancer Institute’s Center for Bioinformatics (NCICB)
  • Caisis [GPL | Windows | web-based] – Caisis is an open-source Web application designed to bridge the gap between clinical research and clinical practice by addressing numerous issues in documentation of patient data. The application was originally designed to track data pertaining to urologic cancer, but now has expanded to track data of other cancers.
    Useful : “The Caisis Project: integrating patient care, research systems and workflows” [2007] by Vora and Fearn.
  • Jumper 2.0 [GPL | multi-platform | web-based] – Bookmarking engine for tagging and linking data objects across remote locations using tag metadata to capture knowledge about data in remote data stores.
  • ·       MIX [GPL | Windows | native] – The MIX program is meta-analysis software for Excel 2000 or later that works like a standalone application. It is thoroughly validated and can be used for educational as well as scientific purposes. (Excel isproprietary software)
  • OpenClinica [LGPL | Linux | web-based] – OpenClinica is a free, open source, web-based electronic data capture (EDC) system for clinical research.
    Useful : “Could an Open-Source Clinical Trial Data-Management System Be What We Have All Been Looking For?” [2008] by Fegan and Lang.
  • ·       Open Infrastructure for Outcomes [GPL | multi-platform | web-based] – OIO is a Web-based medical/patient, user-extensible forms, and online analysis system. It is used at Harbor-UCLA for health/treatment outcomes data. Forms can be exported+imported as XML and exchanged via the online OIO Library at http://www.TxOutcome.Org. ;(last news or releases older than a year)
  • phpESP [BSD | multi-platform | web-based] – php Easy Survey Package (phpESP) is a collection of PHP scripts to let non-technical users create surveys, administer surveys, gather results, view statistics. All managed online after database initialization.
  • PyEPL [LGPL | Mac, Linux | native] – PyEPL (Python Experiment-Programming Library) is a library for coding psychology experiments in Python. It supports presentation of both visual and auditory stimuli, and supports both manual (keyboard/joystick) and sound (microphone) input as responses.
  • R Project [GPL | Windows, Mac, Unix | native]– R is a language and environment for statistical computing and graphics.
    • EpiTools [GPL | see above | see above] – Epidemiology tools (epitools) is an R package for epidemiologic computing and graphics.
    • Surveillance [GPL | see above | see above] – The R-package ’surveillance’ is a framework for the development and the evaluation of outbreak detection algorithms in univariate and multivariate routine collected public health surveillance data.
  • SOFA [LGPL/GPL | Windows, Mac, Linux | native] – Simulation Open-Framework Architecture (SOFA) is an Open Source framework primarily targeted at real-time simulation, with an emphasis on medical simulation. It is mostly intended for the research community to help develop newer algorithms, but can also be used as an efficient prototyping tool.

                                            Clinical Research

       Decision Support: A Survey”[2007] by Leong, Kaiser and Miksch.

                   DICOM Tool(kit)

  • Charrua DICOM Toolkit [GPL | multi-platform | native] – DICOM basic constructs used to create the tools atCharruaSoft.com. Its C++ code is a re-interpretation of the original UCDMC library by Mark Oskin. It tries to be much simpler and compact, also uses many Borland VCL specific structures.
  • dcm4che [MPL, GPL, LGPL | multi-platform | web-based] – Open Source Clinical Image and Object Management.
     Useful: “Benefits of Using the DCM4CHE DICOM Archive” [2007] by Warnock et al.
  • DCMTK – DICOM Toolkit [unknown | Windows, Mac, Linux, Solaris | native] – DCMTK is a collection of libraries and applications implementing large parts the DICOM standard.
  • dicom3tools [BSD | Mac, Linux | native] – Command line utilities for creating, modifying, dumping and validating files of DICOM attributes, and conversion of proprietary image formats to DICOM. Can handle older ACR/NEMA format data, and some proprietary versions of that such as SPI.
  • dicom4j [LGPL, GPL | multi-platform | web-based] – Dicom4j is a free and open source Dicom framework for Java. This framework will help to develop DICOM compliant applications. Dicom4j based applications are available from here.
  • dinifti [BSD | Mac, Linux | native] – The dinifti program converts MRI images stored in DICOM format to NIfTI format.
  • DVTk – DICOM Validation Toolkit [LGPL | Windows | native] – The DVTk project creates different tools that will assist in the development, testing and servicing of Medical Interfaces such as DICOM and HL7.
     Useful : “Mastering DICOM with DVTk” [2007] by Potter et al.
  • GDCM (Grassroots DiCoM) [BSD-like license | multi-platform | native] – Gdcm is yet another C++ library dedicated to reading/parsing and writing Dicom medical files.
  • niftilib [public domain | multi-platform | native] – Niftilib is a set of i/o libraries for reading and writing files in the nifti-1 data format. nifti-1 is a binary file format for storing medical image data, e.g. magnetic resonance image (MRI) and functional MRI (fMRI) brain images. Niftilib currently has C, Java, MATLAB, and Python libraries. It is planned to add some MATLAB/mex interfaces to the C library in the future.
  • openDICOM.NET [GPL, LGPL | Windows, Linux | native] – DICOM library, console tools, DICOM viewer/browser for Mono/.NET and Beagle Desktop Search Plugin. The project supports ACR-NEMA and DICOM file formats and provides transcoding to XML. It is written in C#.
  • Utilities for Patient Data Exchange (UPDE) [LGPL | Windows | native] – A parser for text files to use with some of the utilities provided by the DCMTK from Offis. The purpose is to provide a basic DICOM Modality Worklist Management SCP.
Useful“Evaluation of Open Source DICOM Frameworks” [2006] by Vázquez et al.

                   DICOM Viewer / Server

  • Aeskulap [unknown | Windows, Linux | native] – Aeskulap is a medical image viewer. It is able to load a series of special images stored in the DICOM format for review. Additionally Aeskulap is able to query and fetch DICOM images from archive nodes (also called PACS) over the network.
  • CDMEDIC PACS WEB [ GPL | Linux | native, web-based] – Full featured free PACS based on ctn or dcm4chee, dcmtk and mysql.
  • Conquest DICOM software [unknown | Windows, Linux | native] – Full featured DICOM server based on and heavily extending the public domain UCDMC DICOM code developed by Mark Oskin.
  • ClearCanvas [BSD | Windows | native] – ClearCanvas is a company devoted to creating innovative open source healthcare IT applications. They offer on their homepage a PACS Workstation, a PACS Server, a RIS and a application framework and SDK on which all three applications are based upon. (to download executables registration is required)
  • ImageJ [GPL/LGPL | Windows, Mac, Linux | native, web-based] – ImageJ is a public domain Java image processing program.
  • Java Light PACS Viewer [GPL | multi-platform | native] – jlpv is a Java Light PACS Viewer application useful for review series or images from DICOM data retrieved from the DCM4CHEE PACS system. It also uses ImageJ as a rendering engine or viewer.
  • Kradview [GPLv3 | Linux | native] – Kradview is a GPLed viewer of images obtained for some different sources: X-ray, NMR and DICOM-compatible imaging devices that runs on free operating systems. Its aim is a easy to use DICOM viewer with instant rendering of images, no matter the size and the zoom of the DICOM image. It covers the “let’s see the the X-ray image” need of the medical professional. Kradview as been developed in C and C++ using KDE libraries. The parsing, rendering, and processing routines has been developed in C, and the graphical interface has been developed in C++ and includes the former routines with “extern C” for fast use.
  • OsiriX Imaging Software [GPL | Mac | native] – Open Source PACS Workstation and DICOM Viewer.
  • OpenSourcePACS [LGPL | multi-platform | web-based] – OpenSourcePACS is a free, open source image referral, archiving, routing and viewing system. It adds functionality beyond conventional PACS by integrating wet read functions, implemented through DICOM Presentation State and Structured Reporting standards.
    Useful“OpenSourcePACS: an extensible infrastructure for medical image management.” [2007] by Bui et al.
  • OSPACS [Cranfield Open-Source License | Windows | native] – Open Source Picture Archiving and Communication System (OSPACS) for storing and displaying medical image files. This is currently been used by the Institute of Women’s Health (University College London) to archive ultrasound images from the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) and aims to store more than 100,000 DICOM files.
     Useful“OSPACS: Ultrasound image management system” [2008] by Stott et al.
  • PGCTN [GPL | Mac, Linux | web-based] – Pgctn is open source DICOM server/web-based viewing system. It is made by using PHP and javascript. Postgresql (also MySQL), CTN (also DCM4CHEE), DCMTK and other open source software are used for the back end. The feature is to improve using theAJAX.
  • RT_Image [unkown | Windows | native] – A DICOM-compliant 3D image display, analysis, and segmentation package for incorporating molecular imaging data in radiation oncology
  • Stratos viewer [GPL | multi-platform | web-based] – Stratos viewer is a web based utility to examine DICOM medical images through a Web browser.
           medical imaging?” [2006] by Henriksen et al.

                   Disaster/Disease Management

  • Real-time Outbreak and Disease Surveillance (RODS) [GPL | multi-platform | web-based] – RODS (Real-time Outbreak and Disease Surveillance) is a real-time computer-based public health surveillance system initially developed at the RODS Laboratory, University of Pittsburgh for the early detection of disease outbreaks.
  • Sahana [LGPL | multi-platform | web-based] – Sahana is a Free and Open Source Disaster Management system. It is a web based collaboration tool that addresses the common coordination problems during a disaster from finding missing people, managing aid, managing volunteers, tracking camps effectively between Government groups, the civil society (NGOs) and the victims themselves.
    Useful : “Sahana Publications, Presentations, and Research”
  • TriSano [AGPLv3 | multi-platform | web-based] – TriSano™ is an open source, citizen-focused surveillance and outbreak management system for infectious disease, environmental hazards, and bioterrorism attacks. It allows local, state and federal entities to track, control and ultimately prevent illness and death.
  • Zyxware Health Monitoring System [GPL | multi-platform | web-based] – ZyxwareHMS is a web based disease monitoring for monitoring diseases like chikungunya, malaria – reported by hospitals in a district, county, state or country. There is a reporting & analysis module and a GIS module which displays the data using google maps.
  • CHITS [GPL, QPL | Windows, Linux | web-based] – The Community Health Information Tracking System (CHITS) is an extensible, modular, open source information system for rural health units (initially for the Philippines). It collects existing routine health data from vertical programs in the Field Health Service Information System (FHSIS) and integrates them into a unified, comprehensive computerized information system.
  • ClearHealth [GPL | unknown | web-based] – ClearHealth is a next generation practice management and EMR. It supports Demographics, Scheduling, Full Medical Billing, Disease Management, Decision Support, EPrescribing, HL7, and Web Services.
  • ·       CottageMed™ [GPL | Windows, Mac, Linux | Filemaker based] – CottageMed™ is a FileMaker Pro application that is flexible, ruggedly dependable and HIPAA-secure Electronic Medical Records system (EMR) … with secure and wireless networking, PDA and multiple-office support, prescription writing and cross-platform. (Filemaker Pro is proprietary software)
  • DHIS 2 [BSD | multi-platform | web-based] – The District Health Information System (DHIS) provides means for data entry, report generation, and analysis. It is part of a larger initiative for health care data in developing countries, called the Health Information System Programme (HISP).
  • FFEHR [GPL | Windows, Linux | web-based] – FFEHR is the temporary project name of a software application commissioned by the ASEAN +3 node of the UNDP’s International Open Source Network (UNDP-IOSN) for eventual use as an electronic health record for the healthcare industry. The initial goal of the project is to be able to design a common user interface that is both effective and efficient, and widely acceptable to medical practitioners in thePhilippines and in the future, worldwide.
  • HOSxP [GPL | Windows | native, web-based] – HOSxP is client/server hospital information system using in 150 hospitals in Thailand. HOSxP has many modules which keep data of Patient Image, Symptoms, Physical Condition, Investigation, Diagnosis, Treatment including Procedure / Medication, etc.
  • IndivoHealth [LGPL | multi-platform | native, web-based] – Indivo is a distributed, web-based, personally controlled health record system that is accessible to the nomadic user and built to public standards. The Indivo project includes a pluggable web services API, web-based UI, data subscription framework, etc.

    Electronic Medical Record (EMR aka EPR aka EHR)

           communication” [2007] by Mandl et al.
  • MedClipse [CPL | multi-platform | native] – MedClipse will be an open-source Electronic Medical Record (EMR) software for the swiss general practionner. It will implement things such as agenda, billing (tarmed), medical and administrative data management, prescriptions, referals and other tools.
  • Medical [GPL | Linux | web-based] – Medical is an highly scalable EMR / Hospital Information System (HIS) for OpenERP. It uses industry standards, such WHO ICD-10. The goal is to provide a universal EMR / HIS, where developing countries can also benefit.
  • Med’In Tux [CeCILL | Windows, Mac, Linux | native] – MedinTux is a powerful medical software, multiuser (using MySQL for data storage), easy-to-use (thanks to Qt development toolkit), complete, working from the GP to the hospital. Its unique design makes it the most customisable software you can dream of.
  • MirrorMed [GPL | Linux | web-based] – MirrorMed is a next-generation PHP-based EHR and practice management system.
  • OpenEMR [GPL | Mac, Linux | web-based] – OpenEMR is the complete, user-friendly and affordable electronic medical record system. It is fully compliant with HIPAA and industry standards.
  • OpenMRS [OpenMRS Public License | Windows, Mac, Linux | web-based] – OpenMRS is a community-developed, open-source, enterprise electronic medical record system framework intended to aid resource-constrained healthcare environments.
    Useful : “Cooking Up An Open Source EMR For Developing Countries: OpenMRS – A Recipe For Successful Collaboration” [2006] by Mamlin et al.
  • OpenVista [AGPL | multi-platform | web-based] – OpenVista is a cost-effective, open, trusted and complete EHR which enhances patient safety, increases clinical and operational efficiency and provides an opportunity to improve quality of care delivery.
  • OSCARMcMaster [GPL | multi-platform | web-based] – OSCAR (Open Source Clinical Application and Resource) from McMaster University is a web-based EMR (electronic medical record) system developed for academic primary care clinics yet suitable in specialty and non-teaching practices.
  • PatientOS [GPL | multi-platform | native] – PatientOS has been designed from the outset to be a Healthcare Information System (HIS). The software architecture, design patterns and framework has been built for the complexities and challenges of an enterprise wide information system.
  • Tolven Health Record [LGPL | multi-platform | web-based] – The Tolven platform and ePHR and eCHR applications enable interoperability across electronic health records for consumers and clinicians. Using Java 5, EJB3, Faces, Facelets,AJAX, relational database, and LDAP for security.
  • Ultimate EMR [GPL | Windows, Linux | web-based] – A feature rich Open Source Core Electronic Medical Record for small medical providers developed with Plone/ Python/ Zope. Core EMR functionalities: Patient History, Past Visits, Rx, Health Maint., Allergies, Labs, Vitals, Notes, and Procedures.
  • WorldVistA [GPL | Linux, Windows | native] – WorldVistA EHR is based on the highly acclaimed VistA system of the United States Department of Veterans Affairs (VA).

                   HL7 Tool(kit)

  • HAPI [GPL, MGPL | multi-platform | native] – HAPI (HL7 application programming interface; pronounced “happy”) is a Java-based HL7 2.x parser with support for traditional (ER7) and XML encoding.
  • HL7v3 Test Harness [GPL | Windows | native] – The HL7 Test Harness system is an HL7 v3 message conformance testing application that also provides the ability to simulate the message processing actions of a client and/or server system. The application provides message workflow, format and content testing.
  • NHapi [MPL | multi-platform | native] – .Net version of HAPI Object oriented HL7 2.X parser. HL7 parser/encoder written in Microsoft .Net C#. Can encode/decode both XML and Pipe Delmimited formats.
  • Perl HL7 Toolkit [GPL | multi-platform | native, web-based] – The HL7 toolkit provides a lightweight Perl API for manipulating, sending and receiving HL7 messages, an implementation of a forking HL7 server and an HL7 queue daemon.
  • QuickViewHL7 [AFL | Windows | native] – HL7 file viewer, in tree-view format, with associated segment/field documentation. Basic usage is for testing and bug-tracing HL7 communications applications. Needs .Net Framework 2.0 to run.
  • Ruby HL7 [BSD license | multi-platform | web-based] – Ruby HL7 is a simple library for parsing and generating HL7 2.x messages. 3.x support is planned in the future.
  • OpenRep FREE [GPL | multi-platform | native] – OpenRep is a Java desktop application designed to serve as a homeopathic software with capabilities to open and use multiple repertories, perform repertorizations and view its results, manage patients and view different materia medicae. It is also designed to save and load data in human readable xml format.
  • CARE2X [GPL | Windows, Mac, Linux | web-based] – Care2x integrates data, functions and workflows in a healthcare environment (Hospital/Healthservice Information System, Practice management, Central Data Server, Health Xchange Protocol).
  • Hospital OS [GPL | Windows, Linux | native] – Hospital OS is a hospital information system for small-sized hospitals (100 beds or less, 200 out-patients per day or less). Hospital OS was developed for the healthcare system ofThailand targeting its small community hospitals nation-wide.
  • Mediboard [GPL | multi-platform | web-based] – Mediboard is a web based open source system to manage Healthcare structures. The system is based on a web multi-layers architecture to manage various interconnected modules, using PHP, XML, XHTML, Javascript, CSS, Smarty and PEAR.
  • Open Hospital [GPL | multi-platform | unkown] – Open Hospital – Hospital Information System for Angal – Uganda. Patient management, pharmacy, laboratotry, pregnancy and malnutrition control management. Developed by Informatici Senza Frontiere.
  • OpenMEDIS [GPL | multi-platform | web-based] – OpenMEDIS is a simple, flexible, and standardized tool to collect (inventory) and process (manage) information on health technology infrastructure, e.g. medical devices in low- and middle income countries.
  • TurnHos [GPL | multi-platform | web-based] – TurnHos is based on the system Care2x, integrates data, functions and workflow in an environment of health care, in addition to the administration schedule, print appointments and admission of patients.
  • Bots [GPL | multi-platform | native] – Bots for the translations and communication needed in Electronic Data Interchange (EDI). Bots has three main functions: “Any-to-any-format” data conversions, (Secure) communications and manage and overview EDI data flows.
  • Chiapas [project specific license | Windows | native] – Chiapas is an enterprise level HIPAA data translation package. It supports all major healthcare transactions and a variety of SQL databases and file types, and incorporates a script parser and a GUI studio for development and maintaining specifications.
  • Dataserver [LGPL | multi-platform | native, web-based] – DataServer is an open source XML gateway, specially tailored for the medical domain. DataServer is middleware, situated between clients and traditional Health Information Systems (HIS), Radiology Information Systems (RIS) and Picture Archive and Communication Systems (PACS). It supports relational (SQL), SOAP, and HTTP data sources out of the box, but is highly extensible for custom types.
  • Laika [Apache License | Windows, Linux | unkown] – Laika analyzes and reports on the interoperability capabilities of EHR systems. This includes the testing for certification of EHR software products and networks.
  • Mergence [GPL | multi-platform | native] – Mergence is a high performance, open source HL7 integration engine and application platform.
  • mirth [MPL | unknown | web-based] – Mirth is an open source cross-platform HL7 interface engine that enables bi-directional sending of HL7 messages between systems and applications over multiple transports.
  • Bika LIMS [GPL | multi-platform | web-based] – Bika combines web content management and workflow processing for a one-stop web-based Laboratory Information Management System.
  • OpenELIS [UIRF Open Source Based Public Software License | multi-platform | web-based] – OpenELIS is a robust Enterprise Laboratory Information System built around an extensible and scalable framework. OpenELIS is designed and developed through the collaborative efforts of Public Health Laboratories to accommodate business processes that are common to all public health laboratories; encompassing clinical, environmental, newborn screening, and animal testing. The goal of the OpenELIS team is to develop a state of the art system that is economically sustainable by reducing both initial investment and ongoing maintenance costs.
  • YaNuCa [GPL | multi-platform | web-based] – YaNuCa (Yet Another Nutrition Calculator) is a web-based calculator for enteral and parenteral nutrition in adult intensive care patients. YaNuCa is a JavaScript program using a compact xHTML form as front end, which can easily be used with any JavaScript 1.2+ capable graphical web browser.
  • eleMental Clinic [GPL | Mac, Linux | web-based] – eleMental Clinic is an Open Source medical records management system for mental health professionals.
  • Elexis Praxisprogramm [EPL | multi-platform | native] – An Eclipse RCP program for all aspects of a medical practice: EMR, laboratory findings etc., as well as accounting, billing (Swiss TARMED-System, other systems to be developped) and other daily work.
  • FreeMED [LGPL | Linux | web-based] – Electronic Medical Record and Practice Management system for medical providers that runs in any Web browser in multiple languages. It provides an XML-RPC backend and multiple import and export formats, as well as reporting and other features.
  • Freemed-YiRC [GPL | Linux | web-based] – Freemed-YiRC is a software project which aims to provide a product capable of providing Child Caring agencies/Youth in Residential Care (YiRC) agencies/Foster Care agencies with a fully functional internal case management/information system.
  • GNUmed [GPL | Windows, Mac, Linux | native] – GNUmed is a medical practice management software
  • OpenTAPAS [GPL | multi-platform | native] – Technology Assisted Practice Application Suite (TAPAS) is a term that describes digital tools that assist physicians deliver care in a paper based office. OpenTAPAS builds upon the HL7 compliant Electronic Medical Summary Standard.
  • Res Medicinae [GPL | multi-platform | web-based] – Res Medicinae is the attempt to overcome high pricing in the realm of medical information systems and to provide users with a stable, platform independent, extensive system using latest technology and being open to many other medical systems.
  • SQL Clinic [unknown | multi-platform | web-based] – SQL Clinic is a clinical database/web application for psychiatric providers in the United States. It is written in perl and runs on the GNU/Linux, FreeBSD, Mac OS X and Win32 platforms. It supports three databases: Postgres, MySQL and Oracle (probably inactive, last news/releases 03/2006).
  • MARiS [GPL | multi-platform | web-base] – The MARiS Project goal is to realize a package suite for Radiological Workflow using Open Source tools and technologies in according with IHE guidelines. The architecture of the single packages is based on the concept of IHE actor: this is very useful to develope a system that is an ensamble of single pieces that cooperate together using IHE profiles.
  • BioSig [GPL | multi-platform | native] – BIOSIG is an open source software library for biomedical signal processing. Library works well with Octave and Matlab. Special emphasis is put on EEG/MEG/ECoG, but also other types of biosignals like ECG, EMG, etc. are supported.
  • FSL [FMRIB | Windows, Mac, Linux | native] – FMRIB Software Library (FSL) is a comprehensive library of analysis tools for FMRI, MRI and DTI brain imaging data. FSL is written mainly by members of the Analysis Group, FMRIB, Oxford, UK. FSL runs on Apple and PCs (Linux and Windows), and is very easy to install. Most of the tools can be run both from the command line and as GUIs (”point-and-click” graphical user interfaces).
                   Hospital Management
                   Integration Tool(kit) / Middleware
                   Laboratory
                   Practice Management
                   Radiology
                   Signal Processing
     Part of FSL is FSLView, a viewer for (f)MRI and DTI data.
  • Octave [GPL | multi-platform | native] – GNU Octave is a high-level language, primarily intended for numerical computations. It provides a convenient command line interface for solving linear and nonlinear problems numerically, and for performing other numerical experiments using a language that is mostly compatible with Matlab. It may also be used as a batch-oriented language.
  • Lipsia [GPL | Linux | native] – Leipzig Image Processing and Statistical Inference Algorithms (Lipsia) is a software tool for processing functional magnetic resonance imaging (fMRI) data. It was developed over the course of several years at the Max-Planck-Institute for Human Cognitive and Brain Sciences inLeipzig,Germany.
  • ODIN [GPL | multi-platform | native] – ODIN is a free software framework for rapid prototyping of magnetic resonance imaging (MRI) sequences. The sequences can be tested, simulated and executed on scanner hardware from different manufacturers.
  • PyMVPA [MIT | multi-platform | native] – PyMVPA is a Python module intended to ease pattern classification analyses of large datasets. In the neuroimaging contexts such analysis techniques are also known as decoding or MVPA analysis. PyMVPA provides high-level abstraction of typical processing steps and a number of implementations of some popular algorithms. While it is not limited to the neuroimaging domain, it is eminently suited for such datasets. PyMVPA is truly free software (in every respect) and additionally requires nothing but free-software to run.
  • IPath [GPL | multi-platform | web-based] – iPath is providing a free and open platform for many kind of telemedical applications. iPath-Server, provides a sort of medical BBS to discuss/consult online. Additional modules can be added, e.g. iPath-Microscope for real time telemicroscopy.
  • Xebra [GPL | multi-platform | web-based] – Xebra is an open source platform for web-based distribution and clinical review of medical imaging results. Xebra is based on the latest open industry standards including JPEG2000, WADO and IHE XDS-I. The software provides healthcare organizations and software developers with all the necessary components to securely transmit and review medical images over a network such as the Internet.

                               Telemedicine

                   Visualization
  • 3D Slicer [BSD-like license | Windows, Mac, Linux | native] – The 3D Slicer uniquely integrates several facets of image-guided medicine into a single environment. It provides capabilities for automatic registration (aligning data sets), semi-automatic segmentation (extracting structures such as vessels and tumors from the data), generation of 3D surface models (for viewing the segmented structures), 3D visualization, and quantitative analysis (measuring distances, angles, surface areas, and volumes) of various medical scans.
  • AMIDE [GPL | Windows, Mac, Linux | native] – Amide (Amide’s a Medical Image Data Examiner) is a tool for viewing, registering, and analyzing anatomical and functional volumetric medical imaging data sets. It imports most clinical DICOM files (using the DCMTK library).
  • BioImageXD [GPL | Windows, Mac, Linux | native] – BioImageXD is a free open source software for analysis, processing and 3D rendering of multi dimensional, multi data channel, time series image data from microscopy and other sources.
  • ·       BrainStorm [GPL | Matlab | native] BrainStorm is an integrated free Matlab toolkit dedicated to Magnetoencephalography (MEG) and Electroencephalography (EEG) data visualization and processing. Our intention is to make a comprehensive set of tools available to the scientific community involved in MEG/EEG experimental research. (Matlab is proprietary software)
  • ·       BrainVISA [CeCILL license, GPL | Windows, Mac, Linux | native] – BrainVISA is a software, which embodies an image processing factory. It is distributed with a toolbox of building blocks dedicated to the segmentation of T1-weighted MR images. (last news or releases older than a year)
  • CTSim [GPL | Windows, Linux | native] – CTSim simulates the process of transmitting X-rays through phantom objects. These X-ray data are called projections. CTSim reconstructs the original phantom image from the projections using a variety of algorithms. Additionally, CTSim has a wide array of image analysis and image processing functions.
  • DeVIDE [BSD | Windows, Linux | native] – DeVIDE, or the Delft Visualisation and Image processing Development Environment, is a cross-platform software framework for the rapid prototyping, testing and deployment of visualisation and image processing algorithms. The software was developed within the Visualisation group. DeVIDE’s primary (and currently only) front-end is a data-flow boxes-and-lines network editor. In this regard, it is very similar to AVS, OpenDX, Khoros or VISSION. DeVIDE integrates functionality from libraries such as VTK, ITK, GDCM, DCMTK, numpy and matplotlib. It is being very actively developed.
  • Drishti [GPL | Windows, Mac, Linux | native] – Drishti (meaning “vision” or “insight” in Sanskrit) is a multi-platform, open-source Volume Exploration and Presentation Tool. It was written for visualizing tomography data, electron-microscopy data and so forth.
  • Endrov [BSD license | multi-platform | native] – Endrov is an open-source plugin architecture aimed for image analysis and data processing.
  • Gwyddion [GPL | Windows, Mac, Linux | native] – Gwyddion is a modular program for SPM (scanning probe microscopy) data visualization and analysis. Primarily it is intended for analysis of height fields obtained by means of scanning probe microscopy techniques (AFM, MFM, STM, SNOM/NSOM), however it can be generally used for any other height field and image analysis.
  • ITK [BSD-like license | multi-platform | native] – ITK is an open-source software toolkit for performing registration and segmentation.
  • ITK-SNAP [unknown | Windows, Mac, Linux | native] – ITK-SNAP is a tool for segmenting anatomical structures in medical images. It provides an automatic active contour segmentation pipeline, along with supporting manual segmentation toolbox. ITK-SNAP has a full-featured UI aimed at clinical researchers.
  • MITK [BSD-like license | multi-platform | native] – The Medical Imaging Interaction Toolkit (MITK) is a free open-source software system for development of interactive medical image processing software. MITK combines the Insight Toolkit (ITK) and the Visualization Toolkit (VTK) with PIC-based libraries of the DKFZ. As a toolkit, MITK offers those features that are relevant for the development of interactive medical imaging software covered neither by ITK nor VTK.
  • Ogles [GPL | multi-platform | native] – Ogles is slice data visualization tool based on OpenGL. Ogles started out as a planning system for frame based stereotactic neurosurgery. Current development targets at a framework for neuroanalysis. A simple DICOM reader (SDR) is part of the project.
  • OpenMS [LGPL | Windows, Mac, Linux | native] – An open source framework for LC-MS based proteomics. OpenMS offers datastructures and algorithms for the processing of mass spectrometry data. The library is written in C++.
  • ParaView [BSD-like license | Windows, Mac, Linux | native] – ParaView is an open source, freely available program for parallel, interactive, scientific visualization.
  • TEMPO [GPL | multi-platform | native] – TEMPO (Topographic Eeg Mapping PrOgram) is open source software for 3D visualization of brain electrical activity. TEMPO accepts EEG file in standard EDF format and creates animated sequence of topographic maps.
  • VTK [BSD-like license | multi-platform | native] – The Visualization ToolKit (VTK) is an open source, freely available software system for 3D computer graphics, image processing, and visualization.
  • Voreen [GPL | Windows, Mac, Linux | native] – The goal of the Voreen project is to develop an open source volume rendering engine which allows interactive visualization of volumetric data sets by allowing high flexibility when integrating new visualization techniques.
  • (X)MedCon [LGPL | Windows, Mac, Linux | native] – XMedCon is a medical image conversion utility and library; hereby hoping to lower at least one barrier in medical research projects. The supported formats are: Acr/Nema 2.0, Analyze (SPM), Concorde/µPET, DICOM 3.0, CTI ECAT 6/7, NIfTI-1, InterFile3.3 and PNG or Gif87a/89a.
  • Debian-Med [various | Linux | non-applicable] – Debian-Med is a “Custom Debian Distribution” with the aim to develop Debian into an operating system that is particularly well fit for the requirements for medical practice and research. The goal of Debian-Med is a complete system for all tasks in medical care which is built completely on free software. Talks and further info about Debian-Med can be found here. There is also a Wiki available.
  • EGADSS Decision Support System – Evidence-based Guideline and Decision Support System. Provides patient specific point of care reminders in order to aid physicians provide high quality care. Input/output in the form of HL7 CDA Level 2 documents. Knowledge is encoded using Arden Syntax.
  • iHRIS Software Suite [GPL | Windows, Linux | web-based] – The Capacity Project is developing three free and Open Source core software solutions, each addressing a specific human resources for health (HRH) leadership issue. iHRIS Qualify: a training and licensure tracking database for Linux servers. iHRIS Manage: a human resources management system for Linux servers.iHRIS Plan: workforce planning and modeling software for Linux servers. Offline iHRIS: Windows desktop version of all three components of the iHRIS Suite.
  • Linux For Clinics [GPL | Linux | non-applicable] – The Goal of Linux For Clinics is to create a free medically-themed linux distribution combining the work of Debian-Med with the release schedule and support of Ubuntu. They also have a Blog.
  • Open eHealth Foundation – Agfa HealthCare, InterComponentWare (ICW), and Sun Microsystems Inc. have joined as foundation members the new Open eHealth Foundation. The Open eHealth Foundation will provide software components under an Open Source license that will boost the open standards-based exchange of medical information.
  • OpenEMPI – OpenEMPI seeks to provide an open community towards development and critical evaluation of open source solutions for use as a community or enterprise master patient index (”MPI”).
  • Open Healthcare Framework – The Eclipse Open Healthcare Framework (OHF) is a project within Eclipse formed for the purpose of expediting healthcare informatics technology. The project is composed of extensible frameworks and tools which emphasize the use of existing and emerging standards in order to encourage interoperable open source infrastructure, thereby lowering integration barriers.
  • Open Health Tools – Open Health Tools is an open source community with a vision of enabling a ubiquitous ecosystem where members of the Health and IT professions can collaborate to build interoperable systems that enable patients and their care providers to have access to vital and reliable medical information at the time and place it is needed.
  • OpenMedSpel [GPL | multi-platform | native] – OpenMedSpel is a free and open source USA English medical spelling word list.
  • CEN Technical Committee 251 – Health Informatics – CEN/TC 251 is the body within Europe mandated to develop standards for Health Informatics. (Useful: EN13606-1 documents)
  • DICOM – Digital Imaging and Communications in Medicine. (Useful: DICOM 3 standard definition of 2007)
  • Foundational Model of Anatomy – The Foundational Model of Anatomy Ontology (FMA) is an evolving computer-based knowledge source for biomedical informatics; it is concerned with the representation of classes or types and relationships necessary for the symbolic representation of the phenotypic structure of the human body in a form that is understandable to humans and is also navigable, parseable and interpretable by machine-based systems. Specifically, the FMA is a domain ontology that represents a coherent body of explicit declarative knowledge about human anatomy. Its ontological framework can be applied and extended to all other species. It can be browsed via the Foundational Model Explorer.
  • HL7 – Framework and related standards for the exchange, integration, sharing and retrieval of electronic health information.
  • HXP – HXP is a standard data exchange protocol that could be used by healthcare applications to communicate transparently with each other regardless of their platforms. It is a protocol for making and receiving procedure calls over the internet and thus allow reception and transmission of data among remote healthcare applications.
  • IHE – IHE is an initiative by healthcare professionals and industry to improve the way computer systems in healthcare share information. IHE promotes the coordinates use of established standards such as DICOM and HL7 to address specific clinical need in support of optimal patient care. Systems developed in accordance with IHE communicate with one another better, are easier to implement, and enable care providers to use information more effectively.

                   Other

                   Standards

                   Further Sources

Document Downloads

Leveraging Investments and Sharing Knowledgematrix imaging

LIST OF OPEN SOURCE SOFTWARES

A Bold GNU Head

                   LIST OF OPEN SOURCE SOFTWARES


          Categories

                        Public Health and Bio surveillance

Electronic health or medical record

  • CHITS Community Health Information Tracking System – EHR for public health community centres in developing countries
  • ClearHealth Clearhealth – Flexible and standards compliant EMR/EHR
  • ElementalClinic – open source web-based EMR for mental health written in Perl, licensed under the GPL. Also available as a hosted service.
  • FreeMedForms – open source (c++/Qt4.5) highly dynamic EMR. FreeMedForms is released under the BSD license and is intended to be fully internationalized.
  • GNUmed is a WxPython application that uses PostGreSQL.
  • FFEHR Free Feathers Electronic Health Record – EHR application developed using the Mozilla programming framework. FFEHR can run independently or within the Firefox browser.
  • HealthForge – a .Net e-health groupware solution with EMR, Practice Management and patient/physician connectivity. Built on the popular DotNetNuke framework.
  • Hospital OS Open source hospital information system in Thai
  • HOSxP
  • Indivo – open source, personally controlled health record system that enables patients to own complete, secure copies of their medical records. Powers the Dossia framework
  • Medical a multi-user, highly scalable, centralized Electronic Medical Record (EMR) and Hospital Information System (HIS) for openERP
  • OpenEHR Inter-operable, implementation independent Health Record Specifications [1]
  • OpenEMR an open-source Electronic Medical Record (EMR) software.
  • Open Healthcare
  • OpenMRS is a community-developed, open-source, enterprise EMR framework. Extensible and scalable EMR based on Java.
  • OpenVista is a VistA-based distribution with a cross-platform, GTK/C# based clinical front-end. Both client and server are licensed under the AGPL. Reference deployments in a range of small and large facilities.
  • OSCAR McMaster an open-source Electronic Medical Record (EMR) software. The billing component of the software is specialized for the needs of the Canadian health care providers.
  • PatientOS a rich client open-source EMR designed to evolve to a healthcare information system.
  • SmartCare
  • Tolven Healthcare
  • TORCH – Easy to install and customize EMR application in Python
  • VistA — Veterans Administrations integrated Electronic Health Record and Electronic Image Record system available for non-governmental use on MUMPS licensed systems as WorldVistA.
  • ZEPRS The ZEPRS application is an electronic patient record system that enables clinicians to enter data from patient visits using a web browser.
  • Care2x Hospital information system/practice management system/EHR
  • ClearHealth ClearHealth covers the five major areas of practice operations including scheduling, billing, EMR, HIPAA Security and accounts receivable. It offers a fully comprehensive system which now offers tools like E-Prescribing, Drug Interactions, Electronic Labs and Lab ordering. It is the largest open source healthcare solution serving more than 500 sites including the Primary Care Coalition network in MD with 50 sites and around 100,000 patients.
  • FreeDiams – open source (c++/Qt4.5) prescriber and drugs interactions tester. FreeDiams is released under the BSD license and is intended to be fully internationalized but for now drugs database and interactions database are only available in french.
  • FreeMED is a practice management and electronic and computer records system. It allows the tracking of medical data, in detail, with preservation not just of the diagnosis but the reasons for medical encounters. FreeMED is released under the LGPL GNU license. FreeMED is an HIPAA compliant FOSS Practice Management System that handles billing.
  • MedinTux MedinTux is a French medical practice management system, with a web interface as well as a desktop one, that has been initially to manage a hospital emergency department. Being very modular, it has been extended to run also many different smaller practices. It works on GNU/Linux, Mac OS X, Microsoft Windows
  • MirrorMed MirrorMed is a free and open source EHR and practice management system written in PHP. MirrorMed is a web-based application that is capable of running a healthcare practice. MirrorMed shares code with FreeMED, and OpenEMR. MirrorMed is primarily sponsored by SynSeer.
  • Office Manager Encompassing office management healthcare software for medical practices, doctors groups, DMEs, retailers, etc. It does User/patient management, point of sale, scheduling, sign-in, inventory, insurance claims, accounting, etc. Any OS!
  • Open Dental Dental practice management software wiki article Open dental
  • OpenEMR (see also the OpenEMR wikipedia article)
  • OpenTAPAS Technology Assisted Practice Application Suite (TAPAS) is a term that describes digital tools that assist physicians deliver care in a paper based office
  • Elexis Praxisprogramm is an Eclipse RCP program for all aspects of a medical practice: electronic medical record (EMR), laboratory findings etc., as well as accounting, billing (Swiss TARMED-System, other systems to be developed) and other daily work
  • DHIS Open-source district health management information system and data warehouse (license: BSD license)
  • iHRIS Suite Open source platform for management of human resources for health developed by IntraHealth International and funded by USAID (license: GPLv3)
  • 3D SlicerMedical Visualization and Processing Environment for Research
  • Amide tool for viewing, analyzing, and registering volumetric medical imaging data sets, actively being developed
  • BioImageXD software for analysis, processing and 3D rendering of multi dimensional, multi data channel, time series image data from microscopy and other sources
  • BrainStorm an electro/magnetoencephalography (EEG/MEG) data processing and vizualisation toolbox.
  • BrainVisa a brain imaging package including data processing and visualization capabilities, such as T1-based gyrus segmentation, diffusion-based fibertracking, PET, MEG, EEG and more.
  • CDMedic PACS
  • ClearCanvas Workstation is an open source DICOM workstation and application framework for developing medical imaging applications.
  • CTSIM Computed Tomography Simulator, active development
  • DCM4CHE Open Source Clinical Image and Object Management written in java
  • DCMTK is a collection of libraries and applications implementing large parts the DICOM standard
  • DeVIDE is the open source (BSD-style license) and cross-platform (Windows, Linux) Delft Visualization and Image processing Development Environment, a visual programming system focused on medical visualization and image processing. DeVIDE incorporates VTK, ITK, numpy, matplotlib, DCMTK and GDCM. Latest features include a visual DICOM browser.
  • Dicom4j An open source DICOM Java framework.
  • Dicom4j-apps Free and open-sources DICOM applications in Java.
  • DICOM Router a variety of DICOM related utilities
  • DICOM Validation Tool (DVT) is a software utility and a set of .NET components that will assist in testing the medical / healthcare protocol DICOM. DVT provides you the methods to transfer and validate DICOM objects.
  • Drishti is a volumetric visualisation package for viewing Computer Tomography data. Able to import DICOM image stacks.
  • ecg2png Program designed to convert scanned 12-lead electrocardiograms into PNG format
  • Endrov Image and data viewer and editor
  • Eviewbox Java medical imaging software
  • GDCM Grassroots DiCoM is a C++ library for DICOM medical files. It is automatically wrapped to python/C#/Java (using swig). It supports RAW,JPEG (lossy/lossless), J2K,JPEG-LS,RLE and deflated. It also comes with DICOM Part 3,6 & 7 of the standard as XML files.
  • Imlib3d C++ library for 3D (volumetric) image processing
  • ITK Segmentation and Registration Toolkit
  • ITK-SNAP Interactive software for 3D image navigation, annotation and automatic segmentation
  • kradview Free (GPL) DICOM viewer, for Linux and FreeBSD.
  • METK is an open source toolkit to visualize and explore medical datasets.
  • Miniwebpacs storage, control and recovery of medical images and information in healthcare providers of small and medium capacity. Such system is based on the DICOM standard and in the actual WEB technologies.
  • MITK Medical Imaging Interaction Toolkit
  • NIRFAST NIRFAST is an open source FEM based software package designed for modeling Near Infrared Frequency domain light transport in tissue.
  • O3-RWS is the Radiology Workstation of the Open Three ( O3 ) Consortium. According to the IHE definitions, O3-RWS is an Open Source, DICOM based, Internationalized, Modular and Portable Image Display actor plus the integration of several other IHE actors.
  • OsiriX[3] 3D DICOM Medical Viewer for Mac OS X. Complete DICOM Viewer with DICOM network support
  • Ogles is a three-dimensional volume and slice data visualization tool
  • Opensource PACS Wet Read system includes: image order, image reconciler, radiologist workstation (DICOM viewer), DICOM structured reporting, web-based summary of patient diagnosis. (see Projects under Navigation box)
  • ParaView Large Scale Visualization tool
  • PhP Nuke healthcare PHP-Nuke based system for Health Institutes. X-Ray and Register modules for storing patient data with pictures. System is DICOM compatible
  • Tempo(Topographic Eeg Mapping PrOgram) is open source software for 3D visualization of brain electrical activity
  • Virtual PACS allows radiologists to use a DICOM workstation to access multiple DICOM repositories as a single federated virtualized PACS. The DICOM repositories are exposed on caGrid and can include PACS, image archives such as National Cancer Imaging Archive or other DICOM data warehouses.
  • Voreen stands for Volume Rendering Engine. It is a library providing essential functionality for visually exploring volume data sets. Voreen supports most relevant data formats as for instance DICOM and is currently used in medical visualization as well as for visualizing electron microscopy data.
  • VTK Visualization Toolkit
  • Xebra (medical imaging software)
  • Blood_collection is a Web based software to increase the number of donors in blood collections by managing slots for registrations, with a front-end to delegate the blood collection creation and administration (license: GPL)
  • Caisis is a web based information system for the storage and analysis of cancer patient data intended to bridge the gap between clinic and research (license: GPL)
  • OpenClinica is a web-based application that facilitates electronic data capture in clinical trials. The system is free but commercial support is available (license: LGPL)
  • Open Infrastructure for Outcomes (OIO) system enables clinicians, researchers, and other non-programmers to create and maintain flexible and portable patient/research records
  • OpenMEDIS is a simple, flexible, and standardized Web based tool to collect and process information on health technology infrastructure in low- and middle income countries (license: GPL)
  • Resmedicinae Open source medical information system for GPs (license: GPL)
  • trilonis-mc For managed healthcare group eligibility, billing, capitation, and claims adjudication. Aimed at TPAs, HMOs, PPOs, and self-insured employers. HIPAA compliant. Will handle medical, dental, vision, psych, section 125 and COBRA (license: GPL)
  • Mural Project The Open Source Mural Project from Sun is a robust Master Index. It can be configured as a Master Patient Index, Master Provider Index, or any other Index. Fully extensible and configurable. Many existing installations prove scalability and functionality. By making use of the available PIX/PDQ implementation (http://kenai.com/projects/healthcaresolutions), it is IHE Comliant. Commercial licensing and support are available.
  • HAPI (HL7 application programming interface; pronounced “happy”) is an open-source, object-oriented HL7 2.x parser for Java
  • nHAPI .Net version of HAPI (http://hl7api.sourceforge.net/)
  • HL7 Inspector 2 HL7 analysis and validation tool
  • O3-DPACS stands for “Open Three ( O3 ) – Data & Picture Archiving and Communication System”. O3-DPACS is a DICOM & HL7 based IHE compliant Open Source PACS extended to any type of data
  • Open LIS-HL7 HL7 library written in Delphi 6, last updated in 2002
  • ProtoGen/HL7 an implementation of HL7 in C++, last updated in 2001
  • hl7lib Software implementing Health Level 7 protocols commonly used in the medical industry, last released in the year 2000
  • HL7ImExa is table driven set C routines to encode/decode HL-7 messages, last updated in 1996
  • BioSig library for biomedical signal processing featuring, for example, the analysis of biosignals such as the electroencephalogram (EEG), electrocorticogram (ECoG), electrocardiogram (ECG), electrooculogram (EOG), electromyogram (EMG), respiration, and so on License: GPL
  • ecg2png Program designed to convert scanned 12-lead electrocardiograms into PNG format
  • BioMail is a small web-based application for medical researchers, biologists, and anyone who wants to know the latest information about a disease or a biological phenomenon. It is written to automate searching for recent scientific papers in the PubMed Medline database
  • caGrid is an underlying service oriented infrastructure that supports caBIG, an initiative of the National Cancer Institute
  • Jumper 2.0 is a Science 2.0 technology that uses knowledge tags to capture knowledge about data in remote data stores. It collects these in tag profiles that are stored in a Knowledge base and search engine.
  • MIX Meta Analysis software for Excel
  • OpenClinica is a web-based platform for managing clinical studies, created by Akaza Research. Key functions include EDC, CRF, protocol, and site management.
  • BioLinux
  • Chiapas is a data translation package that handles mapping, encoding and decoding data between ANSI X12 4010A1 HIPAA data files and a variety of text, file, and database data sources. It works as a C#/.NET project add-in or a standalone clearinghouse.
  • GlassFish ESB Robust open source, light weight integration engine making use of JSR-208 (JBI). Full HL7 V2 and V3 support. Many transport protocols supported including Web Services, HL7 MLLP, TCP/IP, file, batch, etc.
  • Mirth is an open source cross-platform interface engine that enables bi-directional sending of HL7, NCPDP, X12 and DICOM messages between systems and applications over multiple transports. It has data translation capabilities between a large number of formats including database, XML, file, HL7 2.x, and HL7 3.
  • Bots Bots open source EDI translator. Any-to any-translations. Supported data formats: hl7 version 3, edifact, XML, X12, SAP idoc, flat-file, JSON. HL7 version 2 is in development.
  • CommCare an application of JavaROSA to support community health workers to plan their day, manage household visits, and report their data. Jointly developed by many organizations including D-tree International, Dimagi, and theUniversity ofWashington.
  • Epihandy Handheld survey/data collection application
  • The EpiSurveyor Project Handheld survey/data collection application
  • FrontlineSMS enables users to send and receive text messages with large groups of people through mobile phones.
  • Gather AED-Satellife standards-based application for data collection and reporting, with pluggable and interchangeable components/modules for data entry from a full range of wired and mobile computing devices
  • InSTEDD Several unique open-source tools for group-based SMS communication, assisted collaboration, real-time analytics, and mesh synchronization based on mobile technologies
  • JavaROSA open-source J2ME platform for data collection and decision support on mobile devices (used by Episurveyor, Epihandy, GATHER, and CommCare listed below)
  • MobilizeMRS Software that enables health workers to utilize electronic medical records remotely via SMS (using OpenMRS).
  • Mobilisr open source enterprise class mobile messaging platform – used in outreach campaigns for HIV
  • MoCa MoCa is a remote medical diagnostics platform for health workers in developing nations.
  • National Heart and Lung Institute medical software for handhelds
  • RapidSMS RapidSMS is a communications platform for coordinating SMS, voice messages, IVR menus, and email with user and group management – developed by UNICEF
  • Ushahidi Allows people to submit crisis information through text messaging using a mobile phone, email or web form. Displays information in map view.
  • GlassFish ESB Robust open source, light weight integration engine making use of JSR-208 (JBI). Full HL7 V2 and V3 support. Many transport protocols supported including Web Services, HL7 MLLP, TCP/IP, file, batch, etc.
  • Jengine apparently dead integration engine project written in java
  • Mirth is an open source cross-platform HL7 interface engine that enables bi-directional sending of HL7 messages[1] between systems and applications over multiple transports.
  • i2b2 – open source, web services framework designed to provide an integrated, intelligent search engine across many different clinical databases (conceptually termed the ‘Clinical Research Chart’ by the developers). Consists of a server ‘Hive’ (loosely coupled functional/messaging units) and a client interface (Eclipse-based or web-based).
  • OpenGalen computer-based multilingual coding system for medicine
  • [4] NHS Common User Interface (CUI) Programme. This enables a common look and feel across the five regions of the NHS as prescribed within the NHS plan.
  • ODIN Object-oriented Development Interface for NMR (Nuclear Magnetic Resonance)
  • ICD National Center for Health Statistics Classification of Diseases and Functioning&Disabilities
  • LOINC Logical Observation Identifiers Names and Codes – database of codes and universal identifiers for laboratory and other clinical observations
  • The National Drug Code Directory National Drug Code Directory
  • IPath open source telemedicine platform
  • ZephyrOpen Open source SDK for Health Monitoring Devices, like Heart rate monitor
  • IHEOS implementation of IHE (Integrating the Healthcare Environment) actors. IHE defines profiles for the use of various standards in the healthcare environment
  • GELLO – GELLO is the ANSI-accredited standard, HL7 Guideline Expression Language, Object Oriented. Gello.org is an effort to build open source authoring tool for creating GELLO expressions for multiple uses – including decision support, drug prior authorization, matching patients to clinical trials, etc.
  • MARiS Project The MARiS Project goal is to realize a package suite for Radiological Workflow using Open Source tools and technologies in according with IHE guidelines. The architecture of the single packages is based on the concept of IHE actor: this is very useful to develop a system that is an ensemble of single pieces that cooperate together using IHE profiles.
  • Mural Project The Open Source Mural Project from Sun is a robust Master Index. It can be configured as a Master Patient Index, and using the available PIX/PDQ implementation (http://kenai.com/projects/healthcaresolutions), it is IHE Comliant
  • HIEOS HIEOS is an open source implementation of IHE Cross Enterprise Document Sharing (XDS.b) and the Cross Community Access (XCA) integration profiles. The HIEOS platform enables secure health information exchange between various health communities, thereby enabling care providers to have longitudinal perspectives of patients’ health records.
  • The Integrating the Healthcare Enterprise (IHE) has developed a range of open-source interoperability testing tools called MESA, KUDU and its next generation tool GAZELLE to test healthcare interoperability according to the standards profiled by IHE in its technical Frameworks (See below Interoperability testing).
  • Tapeworm Gnome-desktop health profiler to keep track of your diet, including calories and %’s of fat, carbs, and protein, exercise, blood glucose, weight, etc…
  • OpenHRE(tm) Browsersoft Inc. OpenHRE Tool Kit – Proven and scalable platform for establishing Health Information Exchanges and deriving Meaningful Use of collected data. Includes Patient Locater Service/MPI, Record Exchange Service, Authentication and Access Control Service and Business Intelligence capabilities. Used to deploy and demonstrate a Nationwide Health Information Network Prototype. Used to deploy working Health Information Exchanges for State, Metropolitan and Rural intiatives.
  • ActiveHealth Open HIE API – example programs for building industry standard HIE web services interfaces to the ActiveHealth platform clinical intelligence services which include the CareEngine advanced clinical decision support, ActivePHR personal health record/health risk assessment, ActiveAdvice care management desktop, and performance measures.
  • RetroGuide epxress – a tool for EHR data analysis (quality improvement, decision support, research) based on workflow technology.
  • Lamdi Linux Anesthesia Modular Devices Interface
  • Physioneta collection of software for
    • WFDB Software for viewing, analyzing, and creating recordings of physiologic signals
    • record an application for capturing data from an HP CMS (Merlin) monitor
    • apdet Hilbert Transform based Sleep Apnea Detection using a Single Lead Electrocardiogram
    • ecgwave QRS detection and waveform boundary recognition using ecgpuwave
    • edr Derive a respiration signal from one or more ECG signals
    • puka software for detection of breaths in strain gauge recordings
    • many more components available in the Physionet Software Index
  • Medical Algorithms Project Not really software or strictly open source but usable medical algorithms nonetheless
  • HL7 Message browser and radiological image distribution. Last build was in 2003
  • MedMapper Medical decision making algorithm tool. Visual design tool generates Tcl/Tk code. Non-programmers can design interactive algorithms. Generates notes for inclusion in medical record. Runs freestanding or in Tcl Plugin.
  • OS-ELN Web based Electronic Lab Notebook
  • hxp Healthcare Xchange Protocol for interoperative communications. Data exchange/transfer, platform independent, XML-RPC, HL7, SOAP, EDIFACT. Not much activity since 2004.
  • OHF Eclipse foundation Healthcare project to create components to improve interoperability in the healthcare industry
  • Ideopass/ component to manage the identity of the patients in healthcare organizations
  • SQLCare is a clinical database/web application for healthcare providers in the United States
  • EGADSS is an open source tool that is designed to work in conjunction with primary care Electronic Medical Record (EMR) systems to provide patient specific point of care reminders in order to aid physicians provide high quality care
  • 03-MARIS HE compliant Department System IHE Order Filler and PPS Manager, for scheduling and workflow management in radiology department
  • 03-RWS IHE compliant Internationalized Modular Portable Radiology workstation
  • 03-TEBAN allows 3D reconstruction of brain electrical activity from magnetic resonance measurements (MRI) and brain activity mapping even in pathological patients.
  • 03-Fat Brother software for monitoring DICOM and HL7 services
  • 03-XDS is an XDS complete System
  • ROC.KIT This application allows for automated calculation of ROC curves (Receiver-Operating-Characteristic) from continuous medical data like laboratory results.
  • MyDrugRef is a social network of clinicians and pharmacists to improve prescribing. The project is based on Ruby on Rails.
  • Debian-Med largest Linux distribution for free medical software — welcomes requests for packaging based on a solid evaluation.
  • The Integrating the Healthcare Enterprise (IHE) has developed a range of open-source interoperability testing tools called MESA, KUDU and its next generation tool GAZELLE to test healthcare interoperability according to the standards profiled by IHE in its technical Frameworks. These tools are used by commercial and open source implementers. In particular they allow to prepare and perform conformance and interoperability testing at the IHE Connectathons, testing events regularly held around the world each involving over 100 systems.
  • The Certification Commission for Healthcare Information Technology (CCHIT) has developed an open-source program called Laika to test EHR software for compliance with
  • CCHIT interoperability standards.
  1.                          Medical Practice Management Software                         Health System Management
  •                          Imaging/Visualization
  •                          Medical Information Systems
  •                          MPI – Master Patient Index
  •                          Standards Libraries
  •                                   Older Libraries
  •                          Signal Processing
  •                          Research
  •                          Operating System
  •                          Data Translation
  •                          Mobile / Handheld Devices
  •                          Integration
  •                          Coding
  •                          data related to the healthcare industry
  •                          Telemedicine
  •                          IHE
  •                          Private Health Record
  •                          Other
  •                          Out of the box distributions
  •                          Interoperability testing

   See also

Available categories:

There are other similar listings to which I referred to while creating this one. For details please see Further Sources at the end of this page.

Project attributes are listed in the following way:

<project name> [<used license> | <platform> | <client type>] – <project description>

<platform>: Lists all platforms on which the application can be installed and executed. In case of a client-server system that offers web-based access, this represents just the supported platform(s) for the server.

<client type>: Specifies the type of client. “native” means that you have to installed some sort of software on your local workstation to be able to access the application. “web-based” means that you can access the application via a Web browser.

<project description>: A short description of the project. Mostly this is just a copy & paste from the homepage of the project or from the related project page at sourceforge.net.

                   Billing

  • FreeB [GPL | unknown | unknown] – FreeB was the first GPL Medical Billing Engine. FreeB supports the HCFA 1500 and X12 837p 4010a formats. FreeB 2.0 (PHP) is developed by Uversa Inc. and SynSeer. FreeB 1.0 (Perl) is still used by the OpenEMR project. FreeB 1.0 was rewritten as REMITT which is used by the FreeMED project.
  • Cancer Biomedical Informatics Grid™ – The National Cancer Institute (NCI) has launched the caBIG™ initiative to accelerate research discoveries and improve patient outcomes by linking researchers, physicians, and patients throughout the cancer community. The caBIG™ community has developed and released a variety of bioinformatics tools of which an overview is available here. For more details refer to the Open Source Project Site of the National Cancer Institute’s Center for Bioinformatics (NCICB)
  • Caisis [GPL | Windows | web-based] – Caisis is an open-source Web application designed to bridge the gap between clinical research and clinical practice by addressing numerous issues in documentation of patient data. The application was originally designed to track data pertaining to urologic cancer, but now has expanded to track data of other cancers.
    Useful : “The Caisis Project: integrating patient care, research systems and workflows” [2007] by Vora and Fearn.
  • Jumper 2.0 [GPL | multi-platform | web-based] – Bookmarking engine for tagging and linking data objects across remote locations using tag metadata to capture knowledge about data in remote data stores.
  • ·       MIX [GPL | Windows | native] – The MIX program is meta-analysis software for Excel 2000 or later that works like a standalone application. It is thoroughly validated and can be used for educational as well as scientific purposes. (Excel is proprietary software)
  • OpenClinica [LGPL | Linux | web-based] – OpenClinica is a free, open source, web-based electronic data capture (EDC) system for clinical research.
    Useful : “Could an Open-Source Clinical Trial Data-Management System Be What We Have All Been Looking For?” [2008] by Fegan and Lang.
  • ·       Open Infrastructure for Outcomes [GPL | multi-platform | web-based] – OIO is a Web-based medical/patient, user-extensible forms, and online analysis system. It is used at Harbor-UCLA for health/treatment outcomes data. Forms can be exported+imported as XML and exchanged via the online OIO Library at http://www.TxOutcome.Org. (last news or releases older than a year)
  • phpESP [BSD | multi-platform | web-based] – php Easy Survey Package (phpESP) is a collection of PHP scripts to let non-technical users create surveys, administer surveys, gather results, view statistics. All managed online after database initialization.
  • PyEPL [LGPL | Mac, Linux | native] – PyEPL (Python Experiment-Programming Library) is a library for coding psychology experiments in Python. It supports presentation of both visual and auditory stimuli, and supports both manual (keyboard/joystick) and sound (microphone) input as responses.
  • R Project [GPL | Windows, Mac, Unix | native]– R is a language and environment for statistical computing and graphics.
    • EpiTools [GPL | see above | see above] – Epidemiology tools (epitools) is an R package for epidemiologic computing and graphics.
    • Surveillance [GPL | see above | see above] – The R-package ’surveillance’ is a framework for the development and the evaluation of outbreak detection algorithms in univariate and multivariate routine collected public health surveillance data.
  • SOFA [LGPL/GPL | Windows, Mac, Linux | native] – Simulation Open-Framework Architecture (SOFA) is an Open Source framework primarily targeted at real-time simulation, with an emphasis on medical simulation. It is mostly intended for the research community to help develop newer algorithms, but can also be used as an efficient prototyping tool.

                   Clinical Research

     Useful: “Free and Open Source Enabling Technologies for Patient-Centric, Guideline-Based Clinical Decision Support: A Survey” [2007] by Leong, Kaiser and Miksch.

                   DICOM Tool(kit)

  • Charrua DICOM Toolkit [GPL | multi-platform | native] – DICOM basic constructs used to create the tools at CharruaSoft.com. Its C++ code is a re-interpretation of the original UCDMC library by Mark Oskin. It tries to be much simpler and compact, also uses many Borland VCL specific structures.
  • dcm4che [MPL, GPL, LGPL | multi-platform | web-based] – Open Source Clinical Image and Object Management.

     Useful: “Benefits of Using the DCM4CHE DICOM Archive” [2007] by Warnock et al.

  • DCMTK – DICOM Toolkit [unknown | Windows, Mac, Linux, Solaris | native] – DCMTK is a collection of libraries and applications implementing large parts the DICOM standard.
  • dicom3tools [BSD | Mac, Linux | native] – Command line utilities for creating, modifying, dumping and validating files of DICOM attributes, and conversion of proprietary image formats to DICOM. Can handle older ACR/NEMA format data, and some proprietary versions of that such as SPI.
  • dicom4j [LGPL, GPL | multi-platform | web-based] – Dicom4j is a free and open source Dicom framework for Java. This framework will help to develop DICOM compliant applications. Dicom4j based applications are available from here.
  • dinifti [BSD | Mac, Linux | native] – The dinifti program converts MRI images stored in DICOM format to NIfTI format.
  • DVTk – DICOM Validation Toolkit [LGPL | Windows | native] – The DVTk project creates different tools that will assist in the development, testing and servicing of Medical Interfaces such as DICOM and HL7.

     Useful : “Mastering DICOM with DVTk” [2007] by Potter et al.

  • GDCM (Grassroots DiCoM) [BSD-like license | multi-platform | native] – Gdcm is yet another C++ library dedicated to reading/parsing and writing Dicom medical files.
  • niftilib [public domain | multi-platform | native] – Niftilib is a set of i/o libraries for reading and writing files in the nifti-1 data format. nifti-1 is a binary file format for storing medical image data, e.g. magnetic resonance image (MRI) and functional MRI (fMRI) brain images. Niftilib currently has C, Java, MATLAB, and Python libraries. It is planned to add some MATLAB/mex interfaces to the C library in the future.
  • openDICOM.NET [GPL, LGPL | Windows, Linux | native] – DICOM library, console tools, DICOM viewer/browser for Mono/.NET and Beagle Desktop Search Plugin. The project supports ACR-NEMA and DICOM file formats and provides transcoding to XML. It is written in C#.
  • Utilities for Patient Data Exchange (UPDE) [LGPL | Windows | native] – A parser for text files to use with some of the utilities provided by the DCMTK from Offis. The purpose is to provide a basic DICOM Modality Worklist Management SCP.

Useful: “Evaluation of Open Source DICOM Frameworks” [2006] by Vázquez et al.

                   DICOM Viewer / Server

  • Aeskulap [unknown | Windows, Linux | native] – Aeskulap is a medical image viewer. It is able to load a series of special images stored in the DICOM format for review. Additionally Aeskulap is able to query and fetch DICOM images from archive nodes (also called PACS) over the network.
  • CDMEDIC PACS WEB [ GPL | Linux | native, web-based] – Full featured free PACS based on ctn or dcm4chee, dcmtk and mysql.
  • Conquest DICOM software [unknown | Windows, Linux | native] – Full featured DICOM server based on and heavily extending the public domain UCDMC DICOM code developed by Mark Oskin.
  • ClearCanvas [BSD | Windows | native] – ClearCanvas is a company devoted to creating innovative open source healthcare IT applications. They offer on their homepage a PACS Workstation, a PACS Server, a RIS and a application framework and SDK on which all three applications are based upon. (to download executables registration is required)
  • ImageJ [GPL/LGPL | Windows, Mac, Linux | native, web-based] – ImageJ is a public domain Java image processing program.
  • Java Light PACS Viewer [GPL | multi-platform | native] – jlpv is a Java Light PACS Viewer application useful for review series or images from DICOM data retrieved from the DCM4CHEE PACS system. It also uses ImageJ as a rendering engine or viewer.
  • Kradview [GPLv3 | Linux | native] – Kradview is a GPLed viewer of images obtained for some different sources: X-ray, NMR and DICOM-compatible imaging devices that runs on free operating systems. Its aim is a easy to use DICOM viewer with instant rendering of images, no matter the size and the zoom of the DICOM image. It covers the “let’s see the the X-ray image” need of the medical professional. Kradview as been developed in C and C++ using KDE libraries. The parsing, rendering, and processing routines has been developed in C, and the graphical interface has been developed in C++ and includes the former routines with “extern C” for fast use.
  • OsiriX Imaging Software [GPL | Mac | native] – Open Source PACS Workstation and DICOM Viewer.
  • OpenSourcePACS [LGPL | multi-platform | web-based] – OpenSourcePACS is a free, open source image referral, archiving, routing and viewing system. It adds functionality beyond conventional PACS by integrating wet read functions, implemented through DICOM Presentation State and Structured Reporting standards.
    Useful: “OpenSourcePACS: an extensible infrastructure for medical image management.” [2007] by Bui et al.
  • OSPACS [Cranfield Open-Source License | Windows | native] – Open Source Picture Archiving and Communication System (OSPACS) for storing and displaying medical image files. This is currently been used by the Institute of Women’s Health (University College London) to archive ultrasound images from the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) and aims to store more than 100,000 DICOM files.

     Useful: “OSPACS: Ultrasound image management system” [2008] by Stott et al.

  • PGCTN [GPL | Mac, Linux | web-based] – Pgctn is open source DICOM server/web-based viewing system. It is made by using PHP and javascript. Postgresql (also MySQL), CTN (also DCM4CHEE), DCMTK and other open source software are used for the back end. The feature is to improve using theAJAX.
  • RT_Image [unkown | Windows | native] – A DICOM-compliant 3D image display, analysis, and segmentation package for incorporating molecular imaging data in radiation oncology
  • Stratos viewer [GPL | multi-platform | web-based] – Stratos viewer is a web based utility to examine DICOM medical images through a Web browser.

     Useful: “Open Source in Imaging Informatics” [2007] by Nagy, “Open source software, the future of medical imaging?” [2006] by Henriksen et al.

                   Disaster/Disease Management

  • Real-time Outbreak and Disease Surveillance (RODS) [GPL | multi-platform | web-based] – RODS (Real-time Outbreak and Disease Surveillance) is a real-time computer-based public health surveillance system initially developed at the RODS Laboratory, University of Pittsburgh for the early detection of disease outbreaks.
  • Sahana [LGPL | multi-platform | web-based] – Sahana is a Free and Open Source Disaster Management system. It is a web based collaboration tool that addresses the common coordination problems during a disaster from finding missing people, managing aid, managing volunteers, tracking camps effectively between Government groups, the civil society (NGOs) and the victims themselves.
    Useful : “Sahana Publications, Presentations, and Research”
  • TriSano [AGPLv3 | multi-platform | web-based] – TriSano™ is an open source, citizen-focused surveillance and outbreak management system for infectious disease, environmental hazards, and bioterrorism attacks. It allows local, state and federal entities to track, control and ultimately prevent illness and death.
  • Zyxware Health Monitoring System [GPL | multi-platform | web-based] – ZyxwareHMS is a web based disease monitoring for monitoring diseases like chikungunya, malaria – reported by hospitals in a district, county, state or country. There is a reporting & analysis module and a GIS module which displays the data using google maps.
  • CHITS [GPL, QPL | Windows, Linux | web-based] – The Community Health Information Tracking System (CHITS) is an extensible, modular, open source information system for rural health units (initially for the Philippines). It collects existing routine health data from vertical programs in the Field Health Service Information System (FHSIS) and integrates them into a unified, comprehensive computerized information system.
  • ClearHealth [GPL | unknown | web-based] – ClearHealth is a next generation practice management and EMR. It supports Demographics, Scheduling, Full Medical Billing, Disease Management, Decision Support, EPrescribing, HL7, and Web Services.
  • ·       CottageMed™ [GPL | Windows, Mac, Linux | Filemaker based] – CottageMed™ is a FileMaker Pro application that is flexible, ruggedly dependable and HIPAA-secure Electronic Medical Records system (EMR) … with secure and wireless networking, PDA and multiple-office support, prescription writing and cross-platform. (Filemaker Pro is proprietary software)
  • DHIS 2 [BSD | multi-platform | web-based] – The District Health Information System (DHIS) provides means for data entry, report generation, and analysis. It is part of a larger initiative for health care data in developing countries, called the Health Information System Programme (HISP).
  • FFEHR [GPL | Windows, Linux | web-based] – FFEHR is the temporary project name of a software application commissioned by the ASEAN +3 node of the UNDP’s International Open Source Network (UNDP-IOSN) for eventual use as an electronic health record for the healthcare industry. The initial goal of the project is to be able to design a common user interface that is both effective and efficient, and widely acceptable to medical practitioners in thePhilippines and in the future, worldwide.
  • HOSxP [GPL | Windows | native, web-based] – HOSxP is client/server hospital information system using in 150 hospitals in Thailand. HOSxP has many modules which keep data of Patient Image, Symptoms, Physical Condition, Investigation, Diagnosis, Treatment including Procedure / Medication, etc.
  • IndivoHealth [LGPL | multi-platform | native, web-based] – Indivo is a distributed, web-based, personally controlled health record system that is accessible to the nomadic user and built to public standards. The Indivo project includes a pluggable web services API, web-based UI, data subscription framework, etc.

                   Electronic Medical Record (EMR aka EPR aka EHR)

     Useful: “Indivo: a personally controlled health record for health information exchange and communication” [2007] by Mandl et al.

  • MedClipse [CPL | multi-platform | native] – MedClipse will be an open-source Electronic Medical Record (EMR) software for the swiss general practionner. It will implement things such as agenda, billing (tarmed), medical and administrative data management, prescriptions, referals and other tools.
  • Medical [GPL | Linux | web-based] – Medical is an highly scalable EMR / Hospital Information System (HIS) for OpenERP. It uses industry standards, such WHO ICD-10. The goal is to provide a universal EMR / HIS, where developing countries can also benefit.
  • Med’In Tux [CeCILL | Windows, Mac, Linux | native] – MedinTux is a powerful medical software, multiuser (using MySQL for data storage), easy-to-use (thanks to Qt development toolkit), complete, working from the GP to the hospital. Its unique design makes it the most customisable software you can dream of.
  • MirrorMed [GPL | Linux | web-based] – MirrorMed is a next-generation PHP-based EHR and practice management system.
  • OpenEMR [GPL | Mac, Linux | web-based] – OpenEMR is the complete, user-friendly and affordable electronic medical record system. It is fully compliant with HIPAA and industry standards.
  • OpenMRS [OpenMRS Public License | Windows, Mac, Linux | web-based] – OpenMRS is a community-developed, open-source, enterprise electronic medical record system framework intended to aid resource-constrained healthcare environments.
    Useful : “Cooking Up An Open Source EMR For Developing Countries: OpenMRS – A Recipe For Successful Collaboration” [2006] by Mamlin et al.
  • OpenVista [AGPL | multi-platform | web-based] – OpenVista is a cost-effective, open, trusted and complete EHR which enhances patient safety, increases clinical and operational efficiency and provides an opportunity to improve quality of care delivery.
  • OSCARMcMaster [GPL | multi-platform | web-based] – OSCAR (Open Source Clinical Application and Resource) from McMaster University is a web-based EMR (electronic medical record) system developed for academic primary care clinics yet suitable in specialty and non-teaching practices.
  • PatientOS [GPL | multi-platform | native] – PatientOS has been designed from the outset to be a Healthcare Information System (HIS). The software architecture, design patterns and framework has been built for the complexities and challenges of an enterprise wide information system.
  • Tolven Health Record [LGPL | multi-platform | web-based] – The Tolven platform and ePHR and eCHR applications enable interoperability across electronic health records for consumers and clinicians. Using Java 5, EJB3, Faces, Facelets,AJAX, relational database, and LDAP for security.
  • Ultimate EMR [GPL | Windows, Linux | web-based] – A feature rich Open Source Core Electronic Medical Record for small medical providers developed with Plone/ Python/ Zope. Core EMR functionalities: Patient History, Past Visits, Rx, Health Maint., Allergies, Labs, Vitals, Notes, and Procedures.
  • WorldVistA [GPL | Linux, Windows | native] – WorldVistA EHR is based on the highly acclaimed VistA system of the United States Department of Veterans Affairs (VA).

     Useful: “Open-Source EHR Systems for Ambulatory Care: A Market Assessment” [2008] by the California HealthCare Foundation.

                   HL7 Tool(kit)

  • HAPI [GPL, MGPL | multi-platform | native] – HAPI (HL7 application programming interface; pronounced “happy”) is a Java-based HL7 2.x parser with support for traditional (ER7) and XML encoding.
  • HL7v3 Test Harness [GPL | Windows | native] – The HL7 Test Harness system is an HL7 v3 message conformance testing application that also provides the ability to simulate the message processing actions of a client and/or server system. The application provides message workflow, format and content testing.
  • NHapi [MPL | multi-platform | native] – .Net version of HAPI Object oriented HL7 2.X parser. HL7 parser/encoder written in Microsoft .Net C#. Can encode/decode both XML and Pipe Delmimited formats.
  • Perl HL7 Toolkit [GPL | multi-platform | native, web-based] – The HL7 toolkit provides a lightweight Perl API for manipulating, sending and receiving HL7 messages, an implementation of a forking HL7 server and an HL7 queue daemon.
  • QuickViewHL7 [AFL | Windows | native] – HL7 file viewer, in tree-view format, with associated segment/field documentation. Basic usage is for testing and bug-tracing HL7 communications applications. Needs .Net Framework 2.0 to run.
  • Ruby HL7 [BSD license | multi-platform | web-based] – Ruby HL7 is a simple library for parsing and generating HL7 2.x messages. 3.x support is planned in the future.
  • OpenRep FREE [GPL | multi-platform | native] – OpenRep is a Java desktop application designed to serve as a homeopathic software with capabilities to open and use multiple repertories, perform repertorizations and view its results, manage patients and view different materia medicae. It is also designed to save and load data in human readable xml format.
  • CARE2X [GPL | Windows, Mac, Linux | web-based] – Care2x integrates data, functions and workflows in a healthcare environment (Hospital/Healthservice Information System, Practice management, Central Data Server, Health Xchange Protocol).
  • Hospital OS [GPL | Windows, Linux | native] – Hospital OS is a hospital information system for small-sized hospitals (100 beds or less, 200 out-patients per day or less). Hospital OS was developed for the healthcare system ofThailand targeting its small community hospitals nation-wide.
  • Mediboard [GPL | multi-platform | web-based] – Mediboard is a web based open source system to manage Healthcare structures. The system is based on a web multi-layers architecture to manage various interconnected modules, using PHP, XML, XHTML, Javascript, CSS, Smarty and PEAR.
  • Open Hospital [GPL | multi-platform | unkown] – Open Hospital – Hospital Information System for Angal – Uganda. Patient management, pharmacy, laboratotry, pregnancy and malnutrition control management. Developed by Informatici Senza Frontiere.
  • OpenMEDIS [GPL | multi-platform | web-based] – OpenMEDIS is a simple, flexible, and standardized tool to collect (inventory) and process (manage) information on health technology infrastructure, e.g. medical devices in low- and middle income countries.
  • TurnHos [GPL | multi-platform | web-based] – TurnHos is based on the system Care2x, integrates data, functions and workflow in an environment of health care, in addition to the administration schedule, print appointments and admission of patients.
  • Bots [GPL | multi-platform | native] – Bots for the translations and communication needed in Electronic Data Interchange (EDI). Bots has three main functions: “Any-to-any-format” data conversions, (Secure) communications and manage and overview EDI data flows.
  • Chiapas [project specific license | Windows | native] – Chiapas is an enterprise level HIPAA data translation package. It supports all major healthcare transactions and a variety of SQL databases and file types, and incorporates a script parser and a GUI studio for development and maintaining specifications.
  • Dataserver [LGPL | multi-platform | native, web-based] – DataServer is an open source XML gateway, specially tailored for the medical domain. DataServer is middleware, situated between clients and traditional Health Information Systems (HIS), Radiology Information Systems (RIS) and Picture Archive and Communication Systems (PACS). It supports relational (SQL), SOAP, and HTTP data sources out of the box, but is highly extensible for custom types.
  • Laika [Apache License | Windows, Linux | unkown] – Laika analyzes and reports on the interoperability capabilities of EHR systems. This includes the testing for certification of EHR software products and networks.
  • Mergence [GPL | multi-platform | native] – Mergence is a high performance, open source HL7 integration engine and application platform.
  • mirth [MPL | unknown | web-based] – Mirth is an open source cross-platform HL7 interface engine that enables bi-directional sending of HL7 messages between systems and applications over multiple transports.
  • Bika LIMS [GPL | multi-platform | web-based] – Bika combines web content management and workflow processing for a one-stop web-based Laboratory Information Management System.
  • OpenELIS [UIRF Open Source Based Public Software License | multi-platform | web-based] – OpenELIS is a robust Enterprise Laboratory Information System built around an extensible and scalable framework. OpenELIS is designed and developed through the collaborative efforts of Public Health Laboratories to accommodate business processes that are common to all public health laboratories; encompassing clinical, environmental, newborn screening, and animal testing. The goal of the OpenELIS team is to develop a state of the art system that is economically sustainable by reducing both initial investment and ongoing maintenance costs.
  • YaNuCa [GPL | multi-platform | web-based] – YaNuCa (Yet Another Nutrition Calculator) is a web-based calculator for enteral and parenteral nutrition in adult intensive care patients. YaNuCa is a JavaScript program using a compact xHTML form as front end, which can easily be used with any JavaScript 1.2+ capable graphical web browser.
  • eleMental Clinic [GPL | Mac, Linux | web-based] – eleMental Clinic is an Open Source medical records management system for mental health professionals.
  • Elexis Praxisprogramm [EPL | multi-platform | native] – An Eclipse RCP program for all aspects of a medical practice: EMR, laboratory findings etc., as well as accounting, billing (Swiss TARMED-System, other systems to be developped) and other daily work.
  • FreeMED [LGPL | Linux | web-based] – Electronic Medical Record and Practice Management system for medical providers that runs in any Web browser in multiple languages. It provides an XML-RPC backend and multiple import and export formats, as well as reporting and other features.
  • Freemed-YiRC [GPL | Linux | web-based] – Freemed-YiRC is a software project which aims to provide a product capable of providing Child Caring agencies/Youth in Residential Care (YiRC) agencies/Foster Care agencies with a fully functional internal case management/information system.
  • GNUmed [GPL | Windows, Mac, Linux | native] – GNUmed is a medical practice management software
  • OpenTAPAS [GPL | multi-platform | native] – Technology Assisted Practice Application Suite (TAPAS) is a term that describes digital tools that assist physicians deliver care in a paper based office. OpenTAPAS builds upon the HL7 compliant Electronic Medical Summary Standard.
  • Res Medicinae [GPL | multi-platform | web-based] – Res Medicinae is the attempt to overcome high pricing in the realm of medical information systems and to provide users with a stable, platform independent, extensive system using latest technology and being open to many other medical systems.
  • SQL Clinic [unknown | multi-platform | web-based] – SQL Clinic is a clinical database/web application for psychiatric providers in the United States. It is written in perl and runs on the GNU/Linux, FreeBSD, Mac OS X and Win32 platforms. It supports three databases: Postgres, MySQL and Oracle (probably inactive, last news/releases 03/2006).
  • MARiS [GPL | multi-platform | web-base] – The MARiS Project goal is to realize a package suite for Radiological Workflow using Open Source tools and technologies in according with IHE guidelines. The architecture of the single packages is based on the concept of IHE actor: this is very useful to develope a system that is an ensamble of single pieces that cooperate together using IHE profiles.
  • BioSig [GPL | multi-platform | native] – BIOSIG is an open source software library for biomedical signal processing. Library works well with Octave and Matlab. Special emphasis is put on EEG/MEG/ECoG, but also other types of biosignals like ECG, EMG, etc. are supported.
  • FSL [FMRIB | Windows, Mac, Linux | native] – FMRIB Software Library (FSL) is a comprehensive library of analysis tools for FMRI, MRI and DTI brain imaging data. FSL is written mainly by members of the Analysis Group, FMRIB, Oxford, UK. FSL runs on Apple and PCs (Linux and Windows), and is very easy to install. Most of the tools can be run both from the command line and as GUIs (”point-and-click” graphical user interfaces).
                   Hospital Management
                   Integration Tool(kit) / Middleware
                   Laboratory
                   Practice Management
                   Radiology
                   Signal Processing
     Part of FSL is FSLView, a viewer for (f)MRI and DTI data.
  • Octave [GPL | multi-platform | native] – GNU Octave is a high-level language, primarily intended for numerical computations. It provides a convenient command line interface for solving linear and nonlinear problems numerically, and for performing other numerical experiments using a language that is mostly compatible with Matlab. It may also be used as a batch-oriented language.
  • Lipsia [GPL | Linux | native] – Leipzig Image Processing and Statistical Inference Algorithms (Lipsia) is a software tool for processing functional magnetic resonance imaging (fMRI) data. It was developed over the course of several years at the Max-Planck-Institute for Human Cognitive and Brain Sciences inLeipzig,Germany.
  • ODIN [GPL | multi-platform | native] – ODIN is a free software framework for rapid prototyping of magnetic resonance imaging (MRI) sequences. The sequences can be tested, simulated and executed on scanner hardware from different manufacturers.
  • PyMVPA [MIT | multi-platform | native] – PyMVPA is a Python module intended to ease pattern classification analyses of large datasets. In the neuroimaging contexts such analysis techniques are also known as decoding or MVPA analysis. PyMVPA provides high-level abstraction of typical processing steps and a number of implementations of some popular algorithms. While it is not limited to the neuroimaging domain, it is eminently suited for such datasets. PyMVPA is truly free software (in every respect) and additionally requires nothing but free-software to run.
  • IPath [GPL | multi-platform | web-based] – iPath is providing a free and open platform for many kind of telemedical applications. iPath-Server, provides a sort of medical BBS to discuss/consult online. Additional modules can be added, e.g. iPath-Microscope for real time telemicroscopy.
  • Xebra [GPL | multi-platform | web-based] – Xebra is an open source platform for web-based distribution and clinical review of medical imaging results. Xebra is based on the latest open industry standards including JPEG2000, WADO and IHE XDS-I. The software provides healthcare organizations and software developers with all the necessary components to securely transmit and review medical images over a network such as the Internet.

                                                                  Telemedicine

.

                   Visualization

  • 3D Slicer [BSD-like license | Windows, Mac, Linux | native] – The 3D Slicer uniquely integrates several facets of image-guided medicine into a single environment. It provides capabilities for automatic registration (aligning data sets), semi-automatic segmentation (extracting structures such as vessels and tumors from the data), generation of 3D surface models (for viewing the segmented structures), 3D visualization, and quantitative analysis (measuring distances, angles, surface areas, and volumes) of various medical scans.
  • AMIDE [GPL | Windows, Mac, Linux | native] – Amide (Amide’s a Medical Image Data Examiner) is a tool for viewing, registering, and analyzing anatomical and functional volumetric medical imaging data sets. It imports most clinical DICOM files (using the DCMTK library).
  • BioImageXD [GPL | Windows, Mac, Linux | native] – BioImageXD is a free open source software for analysis, processing and 3D rendering of multi dimensional, multi data channel, time series image data from microscopy and other sources.
  • ·       BrainStorm [GPL | Matlab | native] BrainStorm is an integrated free Matlab toolkit dedicated to Magnetoencephalography (MEG) and Electroencephalography (EEG) data visualization and processing. Our intention is to make a comprehensive set of tools available to the scientific community involved in MEG/EEG experimental research. (Matlab is proprietary software)
  • ·       BrainVISA [CeCILL license, GPL | Windows, Mac, Linux | native] – BrainVISA is a software, which embodies an image processing factory. It is distributed with a toolbox of building blocks dedicated to the segmentation of T1-weighted MR images. (last news or releases older than a year)
  • CTSim [GPL | Windows, Linux | native] – CTSim simulates the process of transmitting X-rays through phantom objects. These X-ray data are called projections. CTSim reconstructs the original phantom image from the projections using a variety of algorithms. Additionally, CTSim has a wide array of image analysis and image processing functions.
  • DeVIDE [BSD | Windows, Linux | native] – DeVIDE, or the Delft Visualisation and Image processing Development Environment, is a cross-platform software framework for the rapid prototyping, testing and deployment of visualisation and image processing algorithms. The software was developed within the Visualisation group. DeVIDE’s primary (and currently only) front-end is a data-flow boxes-and-lines network editor. In this regard, it is very similar to AVS, OpenDX, Khoros or VISSION. DeVIDE integrates functionality from libraries such as VTK, ITK, GDCM, DCMTK, numpy and matplotlib. It is being very actively developed.
  • Drishti [GPL | Windows, Mac, Linux | native] – Drishti (meaning “vision” or “insight” in Sanskrit) is a multi-platform, open-source Volume Exploration and Presentation Tool. It was written for visualizing tomography data, electron-microscopy data and so forth.
  • Endrov [BSD license | multi-platform | native] – Endrov is an open-source plugin architecture aimed for image analysis and data processing.
  • Gwyddion [GPL | Windows, Mac, Linux | native] – Gwyddion is a modular program for SPM (scanning probe microscopy) data visualization and analysis. Primarily it is intended for analysis of height fields obtained by means of scanning probe microscopy techniques (AFM, MFM, STM, SNOM/NSOM), however it can be generally used for any other height field and image analysis.
  • ITK [BSD-like license | multi-platform | native] – ITK is an open-source software toolkit for performing registration and segmentation.
  • ITK-SNAP [unknown | Windows, Mac, Linux | native] – ITK-SNAP is a tool for segmenting anatomical structures in medical images. It provides an automatic active contour segmentation pipeline, along with supporting manual segmentation toolbox. ITK-SNAP has a full-featured UI aimed at clinical researchers.
  • MITK [BSD-like license | multi-platform | native] – The Medical Imaging Interaction Toolkit (MITK) is a free open-source software system for development of interactive medical image processing software. MITK combines the Insight Toolkit (ITK) and the Visualization Toolkit (VTK) with PIC-based libraries of the DKFZ. As a toolkit, MITK offers those features that are relevant for the development of interactive medical imaging software covered neither by ITK nor VTK.
  • Ogles [GPL | multi-platform | native] – Ogles is slice data visualization tool based on OpenGL. Ogles started out as a planning system for frame based stereotactic neurosurgery. Current development targets at a framework for neuroanalysis. A simple DICOM reader (SDR) is part of the project.
  • OpenMS [LGPL | Windows, Mac, Linux | native] – An open source framework for LC-MS based proteomics. OpenMS offers datastructures and algorithms for the processing of mass spectrometry data. The library is written in C++.

     Useful: “OpenMS – An open-source software framework for mass spectrometry” [2008] by Sturm et al.

  • ParaView [BSD-like license | Windows, Mac, Linux | native] – ParaView is an open source, freely available program for parallel, interactive, scientific visualization.
  • TEMPO [GPL | multi-platform | native] – TEMPO (Topographic Eeg Mapping PrOgram) is open source software for 3D visualization of brain electrical activity. TEMPO accepts EEG file in standard EDF format and creates animated sequence of topographic maps.
  • VTK [BSD-like license | multi-platform | native] – The Visualization ToolKit (VTK) is an open source, freely available software system for 3D computer graphics, image processing, and visualization.
  • Voreen [GPL | Windows, Mac, Linux | native] – The goal of the Voreen project is to develop an open source volume rendering engine which allows interactive visualization of volumetric data sets by allowing high flexibility when integrating new visualization techniques.
  • (X)MedCon [LGPL | Windows, Mac, Linux | native] – XMedCon is a medical image conversion utility and library; hereby hoping to lower at least one barrier in medical research projects. The supported formats are: Acr/Nema 2.0, Analyze (SPM), Concorde/µPET, DICOM 3.0, CTI ECAT 6/7, NIfTI-1, InterFile3.3 and PNG or Gif87a/89a.
  • Debian-Med [various | Linux | non-applicable] – Debian-Med is a “Custom Debian Distribution” with the aim to develop Debian into an operating system that is particularly well fit for the requirements for medical practice and research. The goal of Debian-Med is a complete system for all tasks in medical care which is built completely on free software. Talks and further info about Debian-Med can be found here. There is also a Wiki available.
  • EGADSS Decision Support System – Evidence-based Guideline and Decision Support System. Provides patient specific point of care reminders in order to aid physicians provide high quality care. Input/output in the form of HL7 CDA Level 2 documents. Knowledge is encoded using Arden Syntax.
  • iHRIS Software Suite [GPL | Windows, Linux | web-based] – The Capacity Project is developing three free and Open Source core software solutions, each addressing a specific human resources for health (HRH) leadership issue. iHRIS Qualify: a training and licensure tracking database for Linux servers. iHRIS Manage: a human resources management system for Linux servers. iHRIS Plan: workforce planning and modeling software for Linux servers. Offline iHRIS: Windows desktop version of all three components of the iHRIS Suite.
  • Linux For Clinics [GPL | Linux | non-applicable] – The Goal of Linux For Clinics is to create a free medically-themed linux distribution combining the work of Debian-Med with the release schedule and support of Ubuntu. They also have a Blog.
  • Open eHealth Foundation – Agfa HealthCare, InterComponentWare (ICW), and Sun Microsystems Inc. have joined as foundation members the new Open eHealth Foundation. The Open eHealth Foundation will provide software components under an Open Source license that will boost the open standards-based exchange of medical information.
  • OpenEMPI – OpenEMPI seeks to provide an open community towards development and critical evaluation of open source solutions for use as a community or enterprise master patient index (”MPI”).
  • Open Healthcare Framework – The Eclipse Open Healthcare Framework (OHF) is a project within Eclipse formed for the purpose of expediting healthcare informatics technology. The project is composed of extensible frameworks and tools which emphasize the use of existing and emerging standards in order to encourage interoperable open source infrastructure, thereby lowering integration barriers.
  • Open Health Tools – Open Health Tools is an open source community with a vision of enabling a ubiquitous ecosystem where members of the Health and IT professions can collaborate to build interoperable systems that enable patients and their care providers to have access to vital and reliable medical information at the time and place it is needed.
  • OpenMedSpel [GPL | multi-platform | native] – OpenMedSpel is a free and open source USA English medical spelling word list.
  • CEN Technical Committee 251 – Health Informatics – CEN/TC 251 is the body within Europe mandated to develop standards for Health Informatics. (Useful: EN13606-1 documents)
  • DICOM – Digital Imaging and Communications in Medicine. (Useful: DICOM 3 standard definition of 2007)
  • Foundational Model of Anatomy – The Foundational Model of Anatomy Ontology (FMA) is an evolving computer-based knowledge source for biomedical informatics; it is concerned with the representation of classes or types and relationships necessary for the symbolic representation of the phenotypic structure of the human body in a form that is understandable to humans and is also navigable, parseable and interpretable by machine-based systems. Specifically, the FMA is a domain ontology that represents a coherent body of explicit declarative knowledge about human anatomy. Its ontological framework can be applied and extended to all other species. It can be browsed via the Foundational Model Explorer.
  • HL7 – Framework and related standards for the exchange, integration, sharing and retrieval of electronic health information.
  • HXP – HXP is a standard data exchange protocol that could be used by healthcare applications to communicate transparently with each other regardless of their platforms. It is a protocol for making and receiving procedure calls over the internet and thus allow reception and transmission of data among remote healthcare applications.
  • IHE – IHE is an initiative by healthcare professionals and industry to improve the way computer systems in healthcare share information. IHE promotes the coordinates use of established standards such as DICOM and HL7 to address specific clinical need in support of optimal patient care. Systems developed in accordance with IHE communicate with one another better, are easier to implement, and enable care providers to use information more effectively.

                   Other

                   Standards

     Useful: IHE Technical Frameworks and Integration Profiles

                   Further Sources

Document Downloads

Open-Source EHR Systems for Ambulatory Care: A Market Assessment (529K)

Appendix A to Open-Source EHR Summary: Research Methodology (20K)

Appendix B to Open-Source EHR Summary: General Concepts (674K)

Appendix C to Open-Source EHR Summary: Systems Reviewed in Detail (682K)

Appendix D to Open-Source EHR Summary: Other Noteworthy Systems (39K)

Appendix E to Open-Source EHR Summary: Benefits and Limitations of FOSS EHRs (32K)

Appendix F to Open-Source EHR Summary: Additional FOSS EHR Resources (17K)

Leveraging Investments and Sharing Knowledge

Understanding TUBERCULOSIS

                                                                                                  TUBERCULOSIS:
Portrait of Robert Koch (1843—1910).

Portrait of Robert Koch (1843—1910). (Photo credit: Wikipedia)

The present  global situation

Tuberculosis (TB) has been curable for more than 50 years, yet it continues to cause an immense burden of morbidity and mortality. Approximately one-third of the world’s population is infected with Mycobacterium tuberculosis, with 8 to 10 million developing active TB and ~3 million dying of TB each year (almost half of whom are co-infected with HIV). About 95% of cases occur in low-income countries and 75% are in the 15-50 age group. Both globally and within countries, there is a striking link between poverty and TB.

Two important developments have occurred in the past two decades:

  • TB incidence has increased dramatically in communities highly endemic for HIV.
  • The emergence of drug resistance jeopardizes both individual treatment and control of the disease in communities. In 1993, WHO declared TB a global emergency?
    Map of the 22 HBCs (high-burden countries) tha...

    Modern TB treatment regimens of 6 to 9 months are highly effective in curing patients and preventing transmission. TB treatment is among the most cost effective of all health interventions. In recent years TB has been recognized as a health and development priority with substantial expansion of TB control programmes.Many years of experience, including both disastrous failures and gratifying successes, has led to the recognition of several basic principles of TB treatment and control:TB treatment and control is first and foremost a public health activity since identifying and curing infectious patients is the most important element in reducing transmission in the community.In every setting, TB patients are more likely to be poor and disadvantaged, with more difficulties accessing health care.Thus it is vital that the public sector take responsibility for ensuring the proper functioning of the programme, usually through the establishment of a National Tuberculosis Programme, and that treatment be provided free of charge to patients.Many of the functions of successful TB treatment and control (see box) can only be provided effectively through a well-organized programme structure, usually operating nationwide.Finally, the TB programme must be integrated with the general health services of the community since that is where TB cases present. Elements of the WHO TB control strategySustained political commitmentMicroscopy: case detection among symptomatic patients attending health services using sputum smear microscopySCC/DOT: standardized short-course chemotherapy (SCC) using regimens of 6-8 months for at least all confirmed smear-positive cases. Good case management includes directly observed therapy (DOT) during the intensive phase for all new sputum-positive cases, during the continuation phase of regimens containing rifampicin, and throughout a re-treatment regimen.Drug supply: establishment and maintenance of a system to supply all essential anti-TB drugs, and to ensure no interruption in their availability.Recording and reporting: establishment and maintenance of a standardized recording and reporting system, allowing assessment of treatment results. MicrobiologyMycobacteria are slender, curved, aerobic bacilli whose cell wall components make them acid-fast on Ziehl Neelsen (ZN) staining. Members of the genus Mycobacterium are listed in the box.M. tuberculosis multiplies slowly so that up to 6 weeks are required for culture. Correspondingly, disease due to M. tuberculosis tends to progress slowly, and responds slowly to treatment in comparison with infections due to common pyogenic bacteria.  Transmission M. tuberculosis is acquired by the inhalation of microscopic droplets produced by individuals with active pulmonary TB, during coughing, sneezing, or speaking. Overcrowded, poorly ventilated conditions increase the risk of transmission as does duration of exposure. Other sources of M. tuberculosis infection, except for handling TB cultures in the laboratory, are extremely rare.M. bovis is a pathogen in cattle and can infect a wide range of domestic and wild animals. As with M. tuberculosis, it is primarily transmitted by droplet inhalation, but human infection can occur through ingestion of unpasteurized milk from infected cows. Disease and pathogenesis ZN stain for Myc TB( from Wikipedia)


     TB infection

     Aerosolized droplets containing M. tuberculosis enter alveoli and initiate a non-specific response. The bacilli are ingested by macrophages and transported to regional lymph nodes. They may either be contained there or spread via the lymphatics or bloodstream to other organs.

    With the development of cell-mediated immunity, cytokines secreted by lymphocytes recruit and activate macrophages, which organize into the granulomas characteristic of TB, surrounded by lymphocytes, effectively walling in the organisms.

    In an immunocompetent host, most granulomas heal. They can sometimes be seen on CXR; more commonly the lesion is not detectable radiographically and a positive tuberculin skin test (TST) is the only evidence of infection.

    Although the lesions become fibrotic, bacilli can persist intracellular in macrophages in a quiescent state capable of reactivation at a later time. This is known as  latent tuberculous infection.

    Active TB disease

     On average ~10% of adults infected with M. tuberculosis ultimately develop active TB, with about half of this risk occurring in the first 1-2 years after infection and the other half distributed over the remainder of the individual’s lifetime. A number of factors can substantially increase the risk of disease reactivation

    In a minority of cases, particularly infants or those with depressed cell-mediated immunity, 1° infection is not contained and symptomatic or disseminated disease (progressive 1° TB) develops directly from 1° infection.

    Post-primary TB

     Occurs as a reactivation of latent infection, often years or even decades after the 1° infection. The genus Mycobacterium includes

    • M. tuberculosis complex (M. tuberculosis, M. bovis, M. bovis BCG, M. africanum): very closely related organisms of which M. tuberculosis is the most important human pathogen.
    • M. leprae, the cause of leprosy, is an important mycobacterial pathogen of humans.
    • Mycobacteria other than TB: mainly environmental organisms which cause a spectrum of relatively uncommon human diseases (e.g. M. avium complex, M. kansasii, M. fortuitum, M. marinum.) M. ulcerans is the cause of Buruli ulcer, a destructive cutaneous mycobacteriosis seen with increasing frequency inWest Africa. Person to person transmission has not been observed with these organisms. This group will not be considered further in this chapter.
      Main symptoms of different variants and stages...

      Risk factors for development of active TB disease in individuals infected with M. tuberculosisHIV – the most powerful known factorRecent infection – the risk/year of developing active disease is much greater in the first 1–2 years after infectionAge – weakened immunity at the extremes of ageMalnutrition, including vitamin D deficiencyDiabetes mellitusSilicosisIntercurrent infections (eg. measles, visceral leishmaniasis)Toxic factors (eg. alcohol and smoking)Poverty -probably many biologic mechanisms involvedImmune suppression (e.g. corticosteroid therapy, malignancy)Herd immunity- members of populations with little historical exposure to TB appear to be more susceptible to disease.Clinical featuresMany settings where TB care is provided will not have access to some of the high technology diagnostic equipment mentioned below, which may be required for the diagnosis of less common forms of TB. However, most cases of TB can be diagnosed with very basic resources, in particular smear microscopy.Primary TB: symptomatic primary TB is mainly a disease of children. It may be suspected clinically in the presence of fever, malaise, and cough, particularly in the setting of recent TB exposure. The diagnosis may be assisted by documenting TST conversion or supported by a positive TST in a patient likely to have been negative previously. A positive smear or even culture is uncommon. A CXR may show enlarged hilar or paratracheal lymph nodes with or without lung consolidation. A diagnosis of symptomatic primary TB is an indication for anti-TB therapy. Post-primary or reactivation TB:One or more non-specific systemic symptoms are usually present including weight loss, anorexia, fever, night sweats, or malaise.In adults, pulmonary TB (PTB) is the most common presentation. It is also the most important type of TB epidemiologically since it accounts for most transmission. However, TB may affect any organ in the body resulting in organ-specific symptoms and signs. Extrapulmonary TB is more common in children and in HIV-infected patients.Pulmonary TB (PTB): involves the lung parenchyma. A history of cough is present in most cases. A cough of long duration is unlikely to be due to common respiratory infections, hence cough lasting >2 to 3 weeks is an indication for sputum smear microscopy. The cough may be productive but often is not. Haemoptysis, chest pain, breathlessness may also be present in some patients.Examination is often normal or the findings non-specific. Some patients may look ill and wasted with a fever and tachycardia, but some patients, even with infectious TB, appear surprisingly well. Chest examination may reveal localized crackles or a pleural effusion. Finger clubbing indicates that a diagnosis other than TB is likely, but prolonged PTB or lung damage from past PTB can cause bronchiectasis and clubbing.Approximately 65% of PTB cases are sputum smear positive. Sputum smear positivity is more likely in patients who are (a) most infectious (smear-positive patients are several times more likely to transmit TB than are those who are smear-negative, even if culture positive) and (b) sickest.A positive smear for acid-fast bacilli in a high TB prevalence area almost always indicates TB.Smear-negative pulmonary TB:Smear-negative PTB is common but difficult to diagnose accurately. Underdiagnosis is clearly undesirable since an opportunity for effective treatment is missed. Over diagnosis also creates problems, using scarce resources from a very important health programme, overlooking other treatable diagnoses, and undermining the TB programme’s credibility in the community. Monitoring the proportion of smear-negative vs. smear-positive pulmonary patients in a programme is a useful indicator of any tendency to over diagnosis of TB. Roughly, the expected proportion of smear-positive: smear-negative is 2:1.Pleural TB: An effusion can often be detected on physical examination and confirmed by X-ray or by diagnostic aspiration with a small gauge needle. In high TB endemic areas, and in the absence of obvious alternative explanations such as heart failure, acute pneumonia, or disseminated KS, TB will be the most common cause of a straw-colored effusion. TB effusions are exudates (fluid protein > half that in serum) and the stained smear contains increased lymphocytes but is seldom positive for acid-fast bacilli. Culture of pleural biopsy tissue is very sensitive and histology of the biopsy usually shows granulomas. Complications of pulmonary TB: Haemoptysis can be life-threatening. Pneumothorax can occur. Dissemination to other organs can occur before treatment is started. Chronic complications include post-TB bronchiectasis, extensive lung fibrosis, and aspergillums (fungus balls) in persistent cavities.TB lymphadenitis: can involve any site, most frequently cervical lymph nodes. Nodes may initially be rubbery and non-tender, becoming matted or fluctuant (cold abscess), sometimes progressing to the development of chronic draining sinuses. They may have been present for weeks or months, and are seldom acutely inflamed. Sometimes TB lymph nodes enlarge or discharge during anti-TB therapy. These characteristics, and the asymmetrical involvement, help to distinguish TB adenitis from persistent generalized lymphadenopathy of HIV.Often a needle aspiration will find a pocket of pus in the node, and this may be smear-positive in some cases (especially if HIV infected). Definitive diagnosis is by surgical biopsy with histologic examination and/or culture where available.Bone TB:Most commonly affects the spine (Pott’s disease). Vertebral collapse may ultimately produce a characteristic angular deformity. Some patients develop features of spinal cord compression. Paravertebral cold abscesses or psoas abscesses may accompany Pott’s disease and may be relieved by needle drainage they do not generally require open surgical drainage. The presence of a characteristic kyphosis in a TB-endemic area is virtually diagnostic of spinal TB.X-ray changes with intervertebral disc and adjacent bony involvement +/- paravertebral soft tissue densities are characteristic but do not distinguish between TB and other infections such as brucellosis. A cold abscess when present can be aspirated for culture. Imaging-guided biopsy requires sophisticated resources. Spinal TB responds well to drug treatment.Patients with severe deformities or with progressive neurologic compromise might benefit from neurosurgical stabilization if available, but neurologic improvement often occurs with medical therapy alone. TB of other joints such as hip and knee generally require biopsy for diagnosis and respond well to chemotherapy.CXR

      Miliary TB:

      Most commonly affects infants and the immunosuppressed. There is a history of gradual onset fever, malaise, and weight loss in the absence of other apparent causes. Clinical suspicion is raised in a child with known or likely recent contact with an infectious TB patient. Physical findings are commonly non-specific, but include hepatomegaly, slight splenomegaly, tachypnoea, and neck stiffness (meningitis may complicate military TB). Progression to death occurs in the absence of therapy.

      Chest X-ray characteristically shows diffuse, tiny, nodular opacities. Sputum smear examination and TST are often negative; where available, biopsy of liver, bone marrow, lymph nodes, or lung parenchyma may yield acid-fast bacilli or granulomas.

      TB meningitis

      Most commonly seen in children and the immunosuppressed. Clinical presentation includes headache, irritability, vomiting, decreased consciousness, or any unexplained progressive central neurologic syndrome. The history is usually less acute than in bacterial meningitis. Neck stiffness may be mild at first, later opisthotonus; coma may occur. Cranial nerve palsies (III, IV, VI, and VIII particularly) occur, reflecting basilar distribution of the disease. Seizures and focal neurologic deficits may also occur.

      Diagnosis rests on CSF examination.

      There is typically a lymphocytosis with raised protein and decreased glucose in early disease, mild changes may be present. CSF should also be examined for cryptococcus if there is a possibility of HIV infection. Unless concentrated the CSF is rarely positive for acid-fast bacilli; cultures may become positive in most cases.

      Once a diagnosis has been made on the basis of clinical features, suggestive CSF abnormalities, and the absence of a likely alternative diagnosis, TB treatment should be started immediately.

      The available evidence and most expert opinion support adjunctive therapy with corticosteroids.

        Abdominal TB:

       Gastrointestinal TB may present as partial bowel obstruction with a history of fever. It can occur at any site in the GI tract, most commonly the terminal ileum. The diagnosis is likely to be made at surgery or endoscopy. Granulomatous hepatitis is characterized by a systemic illness with laboratory evidence of cholestasis and diagnosed on liver biopsy. Peritoneal TB may be suspected on the basis of ascites without another obvious cause such as liver disease and portal hypertension the ascites has the same characteristics as TB pleural fluid (see above). The peritoneum has a characteristic appearance on direct inspection; peritoneal biopsy, ideally taken at laparoscopy, with culture and histology provides a definitive diagnosis.

      Pericardial TB:

      Often first suspected on the basis of globular enlargement of the cardiac silhouette on CXR in patients being investigated for a variety of systemic and cardio respiratory symptoms. It is seen more frequently in HIV-infected patients. A pericardial rub or clinical features of tamponade (elevated jugular venous pressure, pulsus paradoxus, hypotension) may be present. Ultrasound readily confirms the presence of an effusion. Pericardial fluid has the same characteristics as pleural fluid (see above). The risk of tamponade acutely, and constriction later on, may be reduced by adding corticosteroids for the first 6-12weeks of TB treatment.

      Genitourinary TB:

      Can involve any part of the male or female genitourinary tract. Presentation is sub acute and diagnosis usually requires TB culture or histology of biopsies. Renal TB presents with dysuria, hematuria, flank pain, or mass. The urine contains pus cells on microscopy, but is negative on culture for common bacteria. Genital tract TB in women presents as infertility, pelvic pain, mass, or abnormal bleeding. Epididymal swelling is the most common presentation of genital TB in males.

      TB in children

      The risk of progression to disease following M. tuberculosis exposure is greater in infants and young children and the death rate may be very high among those infants who develop TB. By contrast, children between around 7 and 12 years of age have the lowest risk of any age group of developing active TB. Even where culture and other facilities are available, diagnosis of childhood TB is difficult. Sputum smears are usually negative in children with PTB.

      A history of close contact with a smear-positive pulmonary TB case is essential information.

      A positive TST is also strongly suggestive of TB in a child with unexplained illness, particularly in younger children in whom the background rate of TST positivity is low.

      Scoring systems have been developed to rationalize the diagnosis of childhood TB none has been well validated, but they may provide useful guidance.

      An aid to diagnosis of TB in children

      • Score chart for child with suspected TB
      Score 0 1 3
      Length of illness <2 weeks 2–4 weeks >4 weeks
      Weight for age >80% 60–80% <60%
      Family TB (past or present) None Reported by family Proved sputum +ve

       

      • Score for other features if present:
      Positive tuberculin skin test (TST) 3
      Large painless lymph nodes: firm, soft, and/or sinus in neck, axilla, and groin 3
      Unexplained fever, night sweats, no response to malaria treatment 2
      Malnutrition, not improving after 4 weeks 3
      Angle deformity of the spine 4
       Joint swelling, bone swelling, or sinuses 3
      Unexplained abdominal mass or ascites 3
      CNS: change in temperament, convulsions, or coma 3

       

      • If the TOTAL score is 7 or more  treat for TB

      Treat children with a score less than 7 if:

      • CXR is characteristic of TB infection, or
      • The child does not respond to two 7-day courses of two different antibiotics

    Footnote

    2 Dr Keith Edwards, University of Papua New Guinea, published in Crofton et al. (1997) Clinical tuberculosis, MacMillan

    Diagnosis

    Sputum smears

    Three sputa should be examined whenever a cough has been present for >2–3 weeks. In patients who travel some distance to the clinic, the 1st specimen is collected at first presentation, the 2nd is an early morning sputum collected at home on the day the patient returns for follow up, and the 3rd is collected in clinic that day.

    In patients who cannot produce sputum, or in suspected PTB with repeated negative sputum smears, induction with 3% hypertonic saline significantly improves the sensitivity of smear and culture. Gastric lavage is useful in children, where culture facilities are available.

    Chest X-ray

    CXR is not routinely necessary for the diagnosis and management of TB. A normal CXR makes PTB unlikely, but CXRs cannot distinguish reliably between TB and other diseases or between changes of current and past TB. The interpretation of CXR varies according to the skill of the reader and between readers. They do not predict infectiousness (as the sputum smear does), nor supply the definitive identification provided by culture. CXR is useful in patients with undiagnosed chest symptoms who are repeatedly smear negative.


    Tuberculin skin testing (TST)

    Relies on the fact that cell-mediated hypersensitivity typically develops within 8 weeks of infection with M. tuberculosis. The test involves intradermal injection of PPD (purified protein derivative). The diameter of skin induration (swelling; not redness) is measured at 48–72 hours. Training and experience in interpreting skin test responses is critical to achieving accurate results. In most situations, 10 mm of induration to a standard tuberculin dose is the cut-off point between positive and negative; 5 mm is considered to be positive in an HIV-infected individual. Both false negative and false positive TST results occur commonly. The stronger the TST response, the less likely it is to be a false positive.

    Uses of the TST

    • Epidemiologic determining prevalence or incidence in populations or specific groups such as health care workers.
    • Diagnostic to aid in assessing the likelihood of TB as the cause of a clinical illness. In high-prevalence countries, this use is largely limited to children because of the high background prevalence of TST positivity in the adult population.
    • Determination of candidates for ˜chemoprophylaxis (e.g. paediatric contacts of pulmonary TB patients, HIV-infected individuals).
    English: Lowenstein-Jensen medium used for gro...

    English: Lowenstein-Jensen medium used for growing Mycobacterium tuberculosis in Mccartney bottle. (Photo credit: Wikipedia)

    The Mantoux skin test consists of an intraderm...

    The Mantoux Test


    Diagnosis of sputum-negative PTB

    Reassessment and repeat sputum examination after 2–3 weeks, following a therapeutic trial of a broad-spectrum antibiotic, may clarify the diagnosis. CXR, interpreted with the cautions mentioned below, may help to estimate the likelihood of TB in suspects who remain smear-negative.

    Before diagnosing smear-negative PTB, consider alternative

    diagnoses such as:

    Pneumonia  Bronchiectasis
    Asthma Lung abscess
    Chronic bronchitis Lung cancer
    Non-TB respiratory complications of HiV infection

     

    In some TB programmes, a decision to start treatment for smear-negative PTB can only be made by a doctor or individual with particular expertise in TB.

    A therapeutic trial of treatment

    A therapeutic trial is widely used by some practitioners to diagnose TB. Therapeutic trials have not been validated, and this approach risks creating confusion among health care workers. If therapeutic trials are to be used, then:

    • All efforts to make a diagnosis should have been exhausted.
    • The endpoint used to determine success or failure should be established before starting treatment and should be objective (eg. fever, weight gain).
    • The duration of the trial should be established at the beginning: fever can be expected to settle within 14 days of starting treatment in most cases, and weight gain should be evident by 4 weeks.
    • The drugs used for the trial should have antimycobacterial activity (isoniazid, ethambutol, and pyrazinamide) but not be effective against other infections (rifampicin and streptomycin)
    • The patient’s status as a trial patient should be clearly established in the local TB programme.

    A false positive TST can be caused by:

    • BCG: TST response following BCG is variable; BCG in infancy is unlikely to account for a strongly positive TST in adulthood
    • Exposure to environmental mycobacteria
    • Incorrect interpretation

    A false negative TST can be caused by:

    • Normal variation
    • Long interval since infection
    • Reduced cell-mediated immune response (HIV, old age, corticosteroid therapy, measles, malnutrition)
    • Severe illness, including overwhelming TB
    • Incorrect TST technique or interpretation

    Treatment

    Aims of treatment

    • To cure the patient.
    • To prevent transmission in the patient’s family and community.
    • To prevent development of resistant bacilli.

    Principles of anti-TB therapy

    • Use at least 2 drugs to which the organism is presumed to be sensitive.
    • Administer treatment for an adequate duration (6–8 months with the regimens used in most national TB programmes).
    • Ensure that each patient completes the full course of therapy with a high level of adherence.

    First- and second-line anti-TB drugs (see box )

    Treatment is the same regardless of disease site, although some advise a prolonged consolidation phase for TB meningitis and bone disease (12 months total). Anti-TB drugs should be provided in the form of fixed-dose combination (FDC) tablets which make monotherapy impossible and provide a further defence against the development of drug resistance.

    Anti-TB drug dosage and standard regimens

    Most national TB programmes have a standard regimen and a re-treatment regimen — the latter for patients who have defaulted, failed treatment, or relapsed.

    Anti-TB drug (abbreviation) Recommended dose (mg/kg)
    od 3 × week
    Isoniazid (H) 5 10
    Rifampicin (R) 10 10
    Pyrazinamide (Z) 25 35
    Streptomycin (S) 15 15
    Ethambutol (E) 15 30
    Thiacetazone (T) 2.5 N/A

     

    First-line regimen (WHO) 2HRZE 4HR or 2HRZE 4H3R3

    • Isoniazid, rifampicin, pyrazinamide, and ethambutol for 2 months
    • Followed by isoniazid and rifampicin either  or 3×/week for4 months

    First-line regimen (International Union against Tuberculosis and Lung Disease)

    2HRZE 6HE

    • Isoniazid, rifampicin, pyrazinamide, and ethambutol od for 2 months
    • Followed by isoniazid and ethambutol od for 6 months

    Re-treatment regimen (defaulters, treatment failure, relapse).

    2HRZES 1eHRZE 5H3R3E3

    • Isoniazid, rifampicin, pyrazinamide, ethambutol, and streptomycin od for 2 months
    • Followed by isoniazid, rifampicin, pyrazinamide, ethambutol od for 1 month
    • Followed by isoniazid, rifampicin, ethambutol 3×/week for 5 months

    Anti-TB drugs

    • Isoniazid(INH): potent anti-TB activity. Main serious adverse effect is liver toxicity.
    • Rifampicin(rifampicin): essential to the success of modern short course TB therapy (<12 months). Rifampicin is characterized by a high rate of drug interactions (induces liver enzymes and lowers serum levels of warfarin, anticonvulsants, oral contraceptives, some antiretrovirals, etc). It can cause hepatitis.
    • Pyrazinamide: sterilizing activity allows treatment courses of 6 months. May cause vomiting, arthralgias, less commonly hepatitis. Contribution to first-line regimens limited largely to the first 2 months of therapy
    • Ethambutol: main role is prevention of resistance to other drugs, particularly when 1° resistance to one or more first-line agents is possible. Main serious adverse effect is ocular toxicity, which is uncommon at recommended doses.
    • Thiacetazone: formerly used in conjunction with isoniazid in the continuation phase. Largely abandoned in high HIV-prevalence countries because of high rates of Stevens Johnson syndrome in HIV-co-infected patients.
    • Streptomycin: now limited to second-line or re-treatment regimens because of the cost of needles and syringes and the desire to avoid unnecessary injections in the HIV era. Ototoxicity (vertigo >hearing loss) and renal toxicity are the main adverse effects. The drug should be avoided or dosage adjusted carefully in renal dysfunction. Contraindicated in pregnancy.

    Special groups

    • Isoniazid causes peripheral neuropathy more commonly in diabetic, malnourished, alcoholic, and pregnant patients; and in those with pre-existing neuropathy. Give pyridoxine 10–15 mg/d to prevent peripheral neuropathy.
    • Women on oral contraceptives must use another form of contraception (e.g. an IUD) during rifampicin therapy and for 4–8 weeks after stopping rifampicin.
    • Pregnancy: TB drugs, except for streptomycin, may be used in pregnancy. Any theoretical risks to the fetus are much less than the risks from untreated TB.

    Third-line anti-TB drugs

    Recently, some programmes have acquired anti-TB drugs for the treatment of multidrug-resistant (MDR) TB. Treatment of MDR TB is much longer (>18 months), much more toxic, much more costly, and considerably less effective than treatment of drug-sensitive TB. Therefore it must only be introduced in settings where a DOTS (directly observed therapy, short course) programme is established and demonstrating good outcomes. MDR TB treatment requires supervision of every treatment dose, a well-structured programme with guidelines, appropriate laboratory resources, assured drug supply, and access to expert advice, as recommended by the WHO ˜Green Light Committee

    Monitoring treatment:

    Sputum-positive patients should be monitored by sputum smear examination after 2 months of treatment and prior to treatment completion. All other patients should be monitored clinically. Monitoring for adverse drug reactions is essential.

    Concordance: patients usually feel better soon after starting treatment, so may lose the motivation to continue therapy for many months. Treatment completion is essential for cure and prevents the development of drug resistance. The treating health care worker and the TB programme must ensure that patients complete TB therapy. This is most likely to succeed if the patient and community are active and informed participants and aware of the risks of drug resistance. The relationship between the patient and program or clinic staff is a major factor promoting concordance.

    Resistance: small numbers of M. tuberculosis are mutants naturally resistant to single TB drugs. Combination chemotherapy ensures that these resistant organisms will be killed by other drugs. Poor choice of treatment or poor concordance with therapy results in selection for these resistant organisms.

    Treatment failure: follow guidelines in the national TB manual or the re-treatment regimen.

    TB control

    Smear-positive PTB patients transmit infection. Curing smear-positive cases is the 1° means of reducing TB transmission in the community.

    Once availability and quality of treatment have been established, the next priority is case finding. This activity must be integrated with the primary health care service since it depends upon recognition and appropriate investigation (most importantly by sputum smear examination) of TB suspects by primary health care workers.

    Bacille Calmette Guerin (BCG):

    is a live attenuated vaccine derived from M bovis. Protective efficacy ranges from 0 to 80% for reasons which remain controversial. BCG provides some protection against miliary TB and TB meningitis, and should be given at birth to all children in high TB-prevalence countries (except those with symptomatic HIV disease). BCG has little or no impact on the rate of infectious TB in a community.

    Household and close contacts of TB cases: Symptomatic contacts should be investigated for active TB. Chemoprophylaxis should be offered to asymptomatic household contacts aged <5 years, of smear-positive PTB patients. In high-prevalence countries, HIV prevention is an important form of TB control.

    Cross-infection control

    Health care workers are exposed to a significant occupational risk of TB, and HIV-infected subjects are at very high risk. The important infection control principles are:

    • Early diagnosis and treatment of patients to minimize the period of infectiousness.
    • Encourage patients to cover their mouths when coughing or sneezing.
    • Early identification and respiratory isolation of TB suspects pending diagnosis.
    • Increased natural ventilation and sunlight in TB wards and clinics.
    • Encourage health care workers to be tested for HIV and employ those with HIV where there is lower risk of TB exposure (e.g. non-clinical jobs, paediatrics).

    Wearing of common surgical masks by staff provides very limited protection against TB. The infectious droplets are too small to be blocked by these masks and the masks do not seal around the mouth.

    In the laboratory, most TB risk occurs in handling of TB cultures. The risk in handling specimens and preparing sputum smears is much lower.

    Patients should cough sputum specimens in a separate, well-ventilated area. Wearing of masks by lab staff is not needed.

    TB and HIV

    TB incidence has increased up to 6-fold in some communities affected by the HIV pandemic. HIV prevalence is up to 80% among TB patients in these places. TB is the most common cause of death in patients with HIV. The main mechanism involved is suppression of cell-mediated immunity (CD4 helper T-cells and macrophages) by HIV which impairs the immune response to TB.

    Differences in management of TB in HIV +ve patients

    Presentation: most patients with HIV-related TB do not know their HIV status. Some have clinical features of HIV infection: oral candidiasis, chronic diarrhoea, skin and hair changes, peripheral neuropathy, herpes zoster scars, etc. However, since TB can occur early during the course of immune suppression, other clinical features of HIV are often absent.

    Extrapulmonary TB is common in HIV +ve patients, particularly lymphadenopathy, pleural and pericardial effusions, miliary TB, and meningitis. However, PTB continues to be the most common form of TB.

    The radiographic appearance of PTB in HIV +ve patients sometimes differs from the classical appearances, roughly according to the individual’s degree of immune suppression. HIV +ve patients less commonly have upper lobe disease and cavities and more commonly have hilar adenopathy, effusions, and miliary and nodular shadowing.

    Diagnosis: sputum smear microscopy is slightly less sensitive in HIV +ve patients. Differential diagnosis of lung disease in the HIV +ve includes:

    • Bacterial (most often pneumococcal) pneumonia: a short history and a response to antibiotic therapy is suggestive.
    • Pneumocystis jiroveci pneumonia: it is less common in some tropical settings but characteristic features are a history of cough and fever for weeks, severe dyspnoea and hypoxia, diffuse changes on X-ray, and a response to high-dose co-trimoxazole therapy.
    • Pulmonary Kaposi’s Sarcoma: most patients have cutaneous or mucosal lesions (e.g. on the hard palate).

    Treatment regimens:

    The same drug regimens are used in HIV +ve and uninfected patients, so knowledge of HIV status is not required to provide anti-TB treatment. Sputum conversion rates and initial cure rates are similar in HIV +ve patients and those without HIV provided modern rifampicin-containing regimens are used.

    Recurrence rates and re-infection rates are higher. Mortality during and after treatment is markedly increased among patients with HIV, with most deaths being due to HIV-related causes other than TB.

    Increasing numbers of patients have access to ART. Treatment with anti-TB and antiretroviral drugs can lead to complex and clinically important drug interactions:

    • Rifampicin reduces serum levels of most protease inhibitors and some non-nucleoside reverse transcriptase inhibitors such as nevirapine.
    • Immune reconstitution reactions can result in temporary clinical deterioration when ART is started early in the course of TB treatment.

    One strategy is to delay ART until completion of the intensive phase of TB treatment and use of a non-rifampicin-containing continuation phase such as 6 months of isoniazid and ethambutol. Seek expert advice if ART and TB therapy are to be given together.

    There are potential benefits to patients with HIV and TB from giving prophylaxis with co-trimoxazole. Consult national guidelines on this issue. Compared to HIV uninfected people, persons with HIV have:

    • A much higher risk of progressive primary disease following infection.
    • A much higher risk of reactivation of latent TB infection — about 10% per year (compared to 10% in a lifetime in HIV uninfected people).
    • After successful treatment of TB, an increased risk of re-infection with a new strain of M. tuberculosis.

    TB increases HIV replication and may enhance progression to AIDS.

    Treatment of latent TB infection in HIV-infected patients:

    HIV +ve individuals, who are also TST-positive and who have no evidence of active TB disease, have significantly less risk of developing active TB if given chemoprophylaxis though the benefit declines with time, especially if the patient continues to live in a community where the risk of is high. TB transmission Isoniazid for 6-9 months is standard, and seems not to cause increased isoniazid resistance.

    Large-scale chemoprophylaxis programmes for people with HIV are uncommon in practice. Care must be taken that anti-TB drugs, especially rifampicin, are not used or distributed in ways that could promote development of resistance.

    HIV testing of TB patients:

    TB patients are a sentinel group, often selected for epidemiologic surveillance of the HIV epidemic. When treating individual patients, there is an ethical obligation to inform patients when strong clinical evidence of HIV infection is found and to provide them with the option of serologic testing to confirm or exclude HIV.

    Whether all TB patients should be offered HIV testing should be determined at local or national level based on availability of testing and counseling resources and care for HIV infection, policies regarding voluntary testing and counseling, anticipated local reaction in relation to stigmatization of TB patients, and other local factors.

    Oxford Handbook of Tropical Medicine, 2nd Edition

    //

Picture archiving and communication system (PACS) in Radiology


Dr Himadri Sikhor Das,MD
Matrix, 1st Byelane Tarun Nagar,
ABC, G.S.Road, Guwahati,
Assam, India, PIN: 781005
Website: http//:www.radiozen.wordpress.com
  
History
The principles of PACS were first discussed at meetings of radiologists in 1982.
Various people are credited with the coinage of the term PACS. Cardiovascular
radiologist Dr Andre Duerinckx reported in 1983 that he had first used the term
in 1981.[10] Dr Samuel Dwyer, though, credits Dr Judith M. Prewitt for
introducing the term. [11]
Dr Harold Glass, a medical physicist working in Londonin the early 1990s
secured UK Government funding and managed the project over many years which transformed Hammersmith Hospitalin London as the first filmless hospital in the United Kingdom. [12] Dr Glass died a few months after the project came live but is credited with being one of the pioneers of PACS.
what does PACS mean: An image as stored on a picture archiving and communication system (PACS) The same image following contrast adjustment, sharpening and measurement tags added by the system In medical imaging, picture archiving and communication systems (PACS) are computers, commonly servers, dedicated to the storage, retrieval, distribution and presentation of images. The medical images are stored in an independent format. The most common format for image storage is DICOM (Digital Imaging and Communications in Medicine). Electronic images and reports are transmitted digitally via PACS; this eliminates the need to manually file, retrieve or transport film jackets. A PACS consists of four major components: the imaging modalities such as CT and MRI, a secured network for the transmission of patient information, workstations for interpreting and reviewing images, and long and short term archives for the storage and retrieval of images and reports. Combined with available and emerging Web technology, PACS has the ability to deliver timely and efficient access to images, interpretations and related data. PACS breaks down the physical and time barriers associated with traditional film-based image retrieval, distribution and display.
 
Types of images
Most PACSs handle images from various medical imaging instruments, including
ultrasound (US), magnetic resonance (MR), positron emission tomography (PET), computed tomography (CT), endoscopy (ENDO), mammograms (MG), digital radiography (DR), computed radiography (CR) etc. (see DICOM Application areas).
Uses
PACS has two main uses:
1.    Hard copy replacement: PACS replaces hard-copy based means of managing 
      medical   images, such as film archives. With the decreasing price of digital    
      storage,   PACSs  provide a growing cost and space advantage over film
       archives  in   addition to the instant access to prior images at the same  
      institution.
2.   Digital copies are referred to as Soft-copy.
3.   Remote access: It expands on the possibilities of conventional systems by   providing 
     capabilities of off-site viewing and reporting (distance education, telediagnosis). It 
      enables practitioners in different physical locations to  access the same information 
     simultaneously for teleradiology.
PACS is offered by virtually all the major medical imaging equipment manufacturers, medical IT companies and many independent software companies. Basic PACS software can be found free on the internet.
One difficult area in PACS is interpreting the DICOM image format. DICOM does not fully specify the metadata tags stored with images to annotate and describe them, so vendors of medical imaging equipment have latitude to create DICOM-compliant files that differ in the meaning and representation of this metadata. A feature common to most PACS is to read the metadata from all the images into a central database, allowing the PACS user to retrieve all images with a common feature no matter the originating instrument. The differences between vendors’ DICOM implementations make this a difficult task.
A PACS can store volume data from exams and reconstruct 3D images. Some medical modality vendors have defined private DICOM tags to introduce added features. Tags like this are permitted according to DICOM protocol and will not impact on the images in most cases, but will not operate when the image is viewed on a different platform.
Architecture
Typically a PACS consists of a central server that stores a database containing the images connected to one or more clients via a LAN or a WAN which provide or utilize the images. More and more PACS include web-based interfaces to utilize the Internet as their means of communication, usually via VPN (Virtual Private Network) or SSL (Secure Sockets Layer). The client side software is often using ActiveX, JavaScript and/or Java. These are considered only suitable for very small practices that do not view studies containing more than one or two images, as web-based viewers are sandboxed by the parent web browser and cannot allocate enough memory to view even modestly sized image data sets. More robust PACS clients are full applications which can utilize the full resources of the computer they are executing on.
Definitions vary, but most claim that for a system to be truly web based, each individual image should have its own URL.[citation needed]Client workstations can use local peripherals for scanning image films into the system, printing image films from the system and interactive display of digital images. PACS workstations offer means of manipulating the images (crop, rotate, zoom, window, level and others).
Modern radiology equipment and modalities feed patient images directly to the PACS in digital form. For backwards compatibility, most hospital imaging departments and radiology practices employ a film digitizer. PACS image backup is a critical, but sometimes overlooked, part of the PACS Architecture (see below). HIPAA requires that backup copies of patient images be made in case of image loss from the PACS. There are several methods of backing up the images, but they typically involve automatically sending copies of the images to a separate computer for storage, preferably off-site.
Querying

The communication with the PACS server is done through dicom objects that are similar to dicom images, but with different tags. A query typically looks as follows:
The client establishes the network connection to the PACS server. The client prepares a query object which is an empty dicom dataset object.   The client fills in the query object with the keys that should be matched.   E.g. to query for a patient ID, the patient ID tag is filled with the patient’s ID.
The client creates empty tags (tags with zero length string values) for all the tags it wishes to receive from the server. E.g. if the client wishes to   receive an id that it can use to receive images (see image retrieval) it   should create the tag SOP InstanceID (0008, 0018) in the query object.  The query object is sent to the server.   The server sends back to the client a list of response dicom objects. The client extracts the tags that are of interest from the response dicom objects.
 Image retrieval
Images are retrieved from a PACS server through a C-MOVE request, as defined by the DICOM network protocol. This request specifies where an image instance should be sent through an identifier known as the destination AETITLE. The server must be configured about the mapping of the AETITLE to a TCP/IP address and port, and as a consequence the server must know in advance all the AETITLEs that it will ever be requested to send images too.
Image backup
Digital medical images are typically stored on a Picture Archiving and Communication System (PACS) for retrieval. Computer images are fragile and can be lost very quickly. It is important (and required in the USA by the Security Rule’s Administrative Safeguards section of HIPAA) that facilities have a backup copy of the images. Some companies, such as Medstrat [1], provide off-site back-up services that cover this requirement.
While each facility is different, the goal in image backup is to make it automatic and as easy to administer as possible. The hope is that the copies won’t ever be needed. But, as with other disaster planning, they need to be available if needed .Ideally, copies of images should be streamed off-site as they are created. (If using the internet, the Security Rule’s Technical Safeguards section of HIPAA requires that the images be encrypted during transmission.) Depending on bandwidth and image volume, this may not be practical. Other options include removable media (hard drives, DVDs or other media that can hold many patients’ images) and/or separate computers. These copies need to be protected.[2]As hard drive and computer prices continue to fall, RAID is losing acceptance as a backup mechanism. RAID doesn’t back up the images to a fully redundant device, but rather writes some redundant information on multiple drives within the same computer. This added complexity brings its own vulnerabilities.[3] The redundant data written on RAID is subject to the same virus, hardware or software problems as the original image, except that it is protected from hard drive failure. Another way to back up data in the PACS environment is using LTO libraries, which uses digital tapes storing up to 800 GB each with the LTO3 type. This puts their stored images on ´\’near line’ status, meaning that the user has to wait some minutes to get their study.
In the event that it is necessary to reconstruct a PACS from the backup images,the backup system should be able to be turned into a “super modality” that simply blasts all of its images back to the PACS.[4] This will allow the PACS to continue receiving current images while also rebuilding its historical images at the same time. When migrating images from one PACS to another, it is sometimes very difficult to get the old PACS to blast the images to the new one. This is another application where backup can be used to “restore” the images to the new PACS. Backup infrastructure is often expensive, semi-autonomous and frequently results in extended downtime. However, it should still be flexible enough to be used for immediate partial or full restores, as well as performing the migration of images to a new PACS.
  
Integration
A chest image displayed via a PACSA full PACS should provide a single point of access for images and their associated data. That is, it should support all digital modalities. Integration with digital mammography has thus far taken a different course than other modalities, however. When an institution implements full field digital mammography (FFDM), it can choose between two options for reading, manipulating, and reporting on the mammograms. The first option is to integrate the digital mammography device with the institution’s general PACS. The second option is to purchase a mammography-only specialty workstation or mini-PACS from the FFDM vendor and thereby isolate FFDM on its own technological island. Most institutions have chosen the latter option to date Some experts consider the failure to integrate a mistake. The specialty workstations/mini-PACS have limited capabilities compared to a full-featured PACS, critics note. They negatively affect the efficiency of the radiology department in other ways, and also add unnecessary expenses and space requirements because the institution is using redundant technology and datasources.
One of the leading critics of the non-integrated approach is radiologist Michael Trambert, who has presented at the Radiological Society of North America conference and published articles on the benefits of integrating digital mammography with an institution’s existing PACS. Trambert bases his advocacy of integration on his experience and research at a clinic in Santa Barbara, Calif.At the clinic, he had access to specialty workstations for digital mammography,as well as a regular PACS workstation that integrated digital mammography with the institution’s general PACS. The specialty workstations were from Hologic, the institution’s FFDM vendor. The integration had been accomplished by DR Systems, the institution’s general PACS vendor and a PACS industry’s pioneer in digital mammography/PACS integration.

In his articles, Trambert has noted the following advantages of integrating
digital mammography with a general PACS:
  1. Ability to easily compare mammograms to other modalities such as breast  MRI’s   or ultrasounds on a single piece of equipment
     2. Avoiding the expense of a separate specialty workstation/mini-PACS and
       associated storage device, while leveraging the institution’s investment in
       its existing PACS
3.  Saving space in the radiology department instead of adding redundant equipment
4. Enabling referring physicians and radiologists to access all radiologic
  studies via a single user interface, rather than learning a new interface for
  a specialty workstation/mini-PACS [7], [8]
In August of 2004, DR Systems was the first to announce that it had received FDA clearance for diagnostic reading of digital mammography images on a PACS [9]. Since that time, other PACS vendors including Care Stream Health, GE Healthcare, Cedara, FUJIFILM, Philips Healthcare, Sectra, Emageon, and Siemens Medical Solutions have also obtained FDA clearance for FFDM.
A full PACS should also interface with existing hospital information systems:
Hospital information system (HIS) and Radiology Information System (RIS). There are several data flowing into PACS as inputs for next procedures and back to HIS as results corresponding inputs:
In: Patient Identification and Orders for examination. These data are sent from HIS to RIS via integration interface, in most of hospital, via HL7   protocol. Patient ID and Orders will be sent to Modality (CT, MR, etc) via Dicom   protocol (Worklist). Images will be created after images scanning and then forwarded to PACS Server. Diagnosis Report is created based on the images retrieved for presenting from PACS Server by physician/radiologist and then  saved to RIS System.
Out: Diagnosis Report and Images created accordingly. Diagnosis Report is sent   back to HIS via HL7 usually and Images are sent back to HIS via DICOM usually   if there is a DICOM Viewer integrated with HIS in hospitals (In most of cases,   Clinical Physician gets reminder of Diagnosis Report coming and then queries   images from PACS Server).
Interfacing between multiple systems provides a more consistent and more reliable dataset:  Less risk of entering an incorrect patient ID for a study – modalities that   support DICOM worklists can retrieve identifying patient information (patient   name, patient number, accession number) for upcoming cases and present that to   the technologist, preventing data entry errors during acquisition. Once the   acquisition is complete, the PACS can compare the embedded image data with a   list of scheduled studies from RIS, and can flag a warning if the image data   does not match a scheduled study.
Data saved in the PACS can be tagged with unique patient identifiers (such as   a social security number or NHS number) obtained from HIS. Providing a robust method of merging datasets from multiple hospitals, even where the different centers use different ID systems internally.
An interface can also improve workflow patterns:
When a study has been reported by a radiologist the PACS can mark it as read.  This avoids needless double-reading. The report can be attached to the images   and be viewable via a single interface.   Improved use of online storage and near line storage in the image archive. The PACS can obtain lists of appointments and admissions in advance, allowing   images to be pre-fetched from near line storage (for example, tape libraries or DVD jukeboxes) onto online disk storage (RAID array).
Recognition of the importance of integration has led a number of suppliers to develop fully integrated RIS/PACS. These may offer a number of advanced features:
Dictation of reports can be integrated into a single system. The recording is automatically sent to a transcript writer’s workstation for typing, but it can also be made available for access by physicians, avoiding typing delays for urgent results, or retained in case of typing error. Provides a single tool for quality control and audit purposes. Rejected images can be tagged, allowing later analysis (as may be required under radiation   protection legislation). Workloads and turn-around time can be reported   automatically for management purposes.
 DICOM Viewers
There are several DICOM Viewers available both free and proprietary. Some of the DICOM Viewers include: Medstrat, eFilm, K-Pacs, DICOM Works, OsiriX,SureVistaVision, UniPACS, Syngo Imaging, VRRender, ImageJ and MicroDicom. Various viewers can connect directly to a PACS server or retrieve images from local storage. Of note, OsiriX is an open-source DICOM viewer.
 Regulatory concerns
In 2008, USFDA published guidance for industry under which the system has
been regulated against 21 CFR 892.2050.[13]
 References
  1. Medstrat HHS cracks down: provider to pay $100,000 in HIPAA penalties over lost  laptops As the number of drives increase, image inconsistency increases “Blast” images to a PACS “A better way: integrating digital mammography with PACS confers numerous benefits for clinicians, IT staff and patients.”  Trambert M. “Digital mammography integrated with PACS: real world issues, considerations, workflow solutions, and reading paradigms.” Semin Breast Dis 9:75-81.
  2. Trambert M. “A perfect match: integrating digital mammography with RIS/PACS and mammographic QA.” RT Image 19 (8)
  3. Trambert M. “Examine PACS: reading digital mammograms on PACS.” RT Image 20
  4. DR Systems (August 30, 2004). DR Systems receives FDA clearance to add digital mammography to PACS. Press release. Retrieved on 2009-8-3.
  5.  Duerinckx AJ, Pisa EJ. Filmless Picture Archiving and Communication System (PACS) in Diagnostic Radiology. Proc SPIE 1982; 318;9-18. Reprinted in IEEE Computer Society Proceedings of PACS’82, order No 388.
  6. Samuel J. Dwyer III. A personalized view of the history of PACS in the USA. In: Proceedings of the SPIE, “Medical Imaging 2000: PACS Design and Evaluation: Engineering and Clinical Issues”, edited by G. James Blaine and Eliot L. Siegel. 2000; 3980:2-9.
  7. Bryan S, Weatherburn GC, Watkins JR, Buxton MJ (1999). “The benefits of hospital-wide picture archiving and communication systems: a survey of        clinical users of radiology services”. Br J Radiol 72 (857): 469–78. PMID 10505012. 
  8. USFDA (30 May 2008). “Guidance for Industry and FDA Staff: Display
      Accessories for Full-Field Digital Mammography Systems-Premarket
       Notification (510(k)) Submissions”.
  1. http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/ucm107549.htm. Retrieved on 10 July 2009. 

  NB: Text is available under the Creative Commons Attribution-Share Alike License;   additional terms may   apply.

Unusual MR presentations of Pyogenic Spondylodiscitis –

Unusual MR presentations of Pyogenic Spondylodiscitis –

H.S.Das N. Medhi, P.Sarma, P.Goswami, , P.Hazarika.

Infective (Pyogenic and tubercular) spondylitis is a relatively common entity in day-to-day practice. Though commonest cause of such infection is tuberculosis in our country, pyogenic infection of the spine is also frequently encountered. Majority of these pyogenic infections of the spine are iatrogenic in nature, though in some cases the cause and source of infection cannot be ascertained. We report 4 patients of infective spondylodiscitis with unusual presentations.

Case-1: 43 yrs female patient had laparoscopic cholecystectomy in a local hospital. She was nondiabetic and nonhypertensive and blood examination revealed mild anemia and slight rise in the TSH. After surgery was uneventful and she was kept in the intensive care unit overnight and sent to the paying ward after 24 yrs. Her immediate postoperative status was perfectly all right. On 2nd postoperative night she developed excruciating pain and she got partial relief of pain after putting her on continuous parenteral analgesics. Though her pain remained unaltered she was discharged on the 4th day only with analgesics. As pain did not subside an MR examination of the cervical spine was performed. MRI showed significant loss of cervical lordosis with hazy epidural space and provisionally the treatment was continued as cervical sprain. She continued to have pain and later on she developed difficulty in lifting the head. Second MR was performed on 3rd week due to detorioration of her condition and showed evidence of spondylodiscitis at C5-C6 level. She was provisionally put on antibiotics (amikacin 500 mg iv x2weeks followed orally for 6weeks).

Case no 2. 35 yrs old patient had tonsillectomy for chronic tonsillitis. The surgery was carried under general anaesthesia and it was uneventful as far as the primary disease is concerned. He was non-diabetic and nonhypertensive. On third postoperative day the patient developed severe pain in the neck with out significant radicular pain. He was discharged from the hospital with simple analgesic without significant improvement in the condition of the neck pain. As patient deteriorates further an MR examination was performed. MR study reveals involvement of the C5-C6 disc by T2 hyperintense collection, marrow edema involving C5 and C6 vertebral bodies, prevertebral and epidural soft tissue collection. Due to significant compression of the cord surgery was performed to relive the compression and to get a histological diagnosis. At surgery the involved bones were very soft and infected material was removed from the site. Bacteriological and histological diagnosis was pyogenic infection and culture shows growth of pseudomonas infection. The organisms were sensitive to amikacin and gentamycin. Patient improved after surgery.

Case. No 3: 28 yrs female patient had CS under GA. The patient was not diabetic and nonhypertensive. Her pre operative blood and other laboratory parameters were grossly normal. The patient developed severe pain in the neck on 3rd postoperative day. She was also managed by rest and analgesics thinking it to be cervical spondylosis. As her status remains same in spite of rest and analgesics she was investigated by cervical MR. The MR showed features of spondylodiscitis at C5-C6 level with significant thecal compression by the epidural soft tissue component. There was prevertebral abscess also. As her condition continues to deteriorates decompressive surgery was performed. At surgery thick pus with granulation tissue was removed and sent for biopsy and bacteriological study. At pathology features were suggestive of pyogenic spondylodiscitis with salmonella infection. The organisms were sensitive to ciprofloxacin group of antibiotics and not very sensitive to the amikacin and gentamycin. She was put on parenteral antibiotics for 2weeks followed by oral antibiotics for 6weeks. She was completely free from all symptoms.

Case 4: 30 yrs female patient had undergone CS operation. She developed severe pain in the neck on third day of her surgery. Though she was treated with neck exercise and analgesic she continued to deteroriorate and an MR examination was called for. MR study of the cervical spine reveals evidence of spondylodiscitis at C5-C6 vertebral body with epidural and prevertebral collection with mild cord impingement. She was treated was lost to follow up.

Important observations:

- All the patients were operated in the same hospital.

- All 4 patients were operated within the month of June and July. No such patients were reported before or after this period.

- The surgeons were different in all of the cases.

- All patients had involvement of the C5-C6 levels.

- Clinical presentation and course of the disease were almost similar.

Discussion:

Spondylitis is a condition where there is primary infection of the vertebral body. Disc space involvement is called discitis. Pure vertebral osteomyelitis or discitis is infrequent and most of the time there is involvement of both vertebrae and disc hence term spondylodiscitis is preferred. The third element of the spinal infection is the epidural abscess, which is also frequently associated with spondylodiscitis.

Types of spondylodiscitis: According to the offending organism the spondylodiscitis may be pyogenic or Tubercular, though rarely other organisms like Brucella, Fungal or parasites may cause spondylodiscitis.

Pyogenic spondylodiscitis
Pyogenic infection of the spine can occur by three routes- hematogenous spread, direct inoculation and contiguous spread.

Though apparent source of infection in a patient with spondylodiscitis can not be traced even after through check up in most of the patients, the common source of hematogenous spread is from infections of the urinary tract, lungs, pelvis and skin. IV injections may be the source of infection in some patients developing spondylodiscitis after surgery. In diabetics and immuno-compromised patients, a spinal infection is relatively more frequent. The disc is directly infected in children in hematogenous route due to persistence of peridiscal blood vessels. But in adult the disc is avascular and is secondarily affected.

Pyogenic spondylodiscitis can occur by direct inoculation of the disc or contiguous spread of infection. A major proportion of this type of infection is iatrogenic. Iatrogenic disc space infection is most commonly encountered following spinal surgery. This is true in our experience also, where majority of pyogenic spondylodiscitis is due to lumbar disc surgery. This is due to various factors -firstly the lumbar disc surgeries are relatively common; secondly UTI and other pelvic infections frequently involve the lumbar spine. Majority of pyogenic infections are due to staphylococcus aureus and enterobacter group. Other organisms causing pyogenic spondylodiscitis are salmonella and serratia etc.

MR findings- MRI is the single most valuable imaging technique in evaluation of pyogenic spondylodiscitis. MRI can pick up the changes at the earliest stage so that these patients can be treated soon and hence the morbidity is significantly reduced. Involved vertebral bodies reveal increased signal intensity on T2 weighted images and reduced signal intensity on T1 weighted images due to marrow edema. The intervertebral disc reveal reduced signal intensity on T1 weighted images and strong / very strong signal intensity on T2 weighted images sometimes called “hot disc”. There is irregularity in the vertebral end plates with destruction sometimes.
In more advanced cases there is progressive destruction of the vertebral bodies. There is prevertebral soft tissue and epidural lesions in advanced cases.

Tubercular Spondylodiscitis: TB spondylodiscitis most commonly occurs by hematogenous route and generally affects all age groups. The vertebral body is primarily involved with secondary involvement of the appendages, disc and epidural space. There may be involvement of the cord also producing intra-medullary tuberculoma. Lower thoracic and upper lumbar vertebrae are more commonly affected.

MRI findings MR usually pick up the findings very early. There is involvement of two contiguous vertebral bodies including the disc. Involvement of more than two vertebral bodies and areas of skip lesions are frequently encountered. The involved vertebral bodies reveal reduced signal intensity on T1 weighted images and appear iso to hyperintense on T1 weighted images. There is involvement of the posterior elements and lot of epidural granulation tissue or frank collection is seen. Arachnoiditis and intra-medullary tuberculomas may be found.

click to see picture: tb-spine-photo

MR findings of TB Vs Pyogenic spondylodiscitis

  1. Disc space involvement is common in pyogenic infection. The disc becomes hyperintense on T2 weighted images classically described as “hot disc”.
  2. In tubercular infection the posterior elements are also involved which is uncommon in hematogenous pyogenic infection.
  3. More than two vertebral body segments are frequent in TB and there are skip lesions in some cases.
  4. Epidural space, spinal meninges and cord involvement more frequent in TB than pyogenic infection.

Other infections:

Other uncommon causes of spondylodiscitis are Brucella, fungal and rarely parasitic. Brucella spondylitis is characterized by erosion of the anterior aspect of the superior end plate. There is significant sclerosis along with lytic lesions. In fungal spondylitis the responsible organisms are blastomycosis, cryptococcosis and coccidiomycosis. There are destructive lesions, paravertebral soft tissue mass, multiple sites of involvement and relative sparing of the disc are some of the features of fungal spondylodiscitis.

Conclusion: MRI plays a vital role in diagnosis and management of spondylodiscitis. It has highest sensitivity in diagnosis such cases, where it can characterize most of these patients. Unusual presentation of infective spondylitis may cause confusion in diagnosis; FNAC or biopsy may be necessary in some of these patients. Difficulties may arise in differentiating spondylodiscitis with type-1 end plate change, where contrast study may be helpful. Similar problems may arise in cases where infection co-exists in pre existing tumor, where biopsy will give the final diagnosis.

Functional Magnetic Resonance Imaging (fMRI) in Neuroradiology:

DTI Color Map
Image via Wikipedia


Functional Magnetic Resonance Imaging (fMRI) in Neuroradiology:

Dr Himadri S.Das

First, the most commonly used fMRI technique called BOLD-fMRI (Blood-Oxygen-Level-dependent fMRI) potentially offers imaging with a temporal resolution on the order of 100 milliseconds and a spatial resolution of 1-2 millimeters, which is much greater than that of PET and SPECT scanning. This means that transient cognitive events can potentially be imaged and small structures like the amygdala can be more readily resolved. Most fMRI techniques are noninvasive and do not involve the injection of radioactive materials so that a person can be imaged repeatedly. This allows imaging of a patient repeatedly through different disease states or developmental changes Third, with fMRI, one can easily make statistical statements in comparing different functional states within an individual in a single session. Thus, fMRI may be of important use in understanding how a given individual’s brain functions and perhaps, in the future, making psychiatric diagnoses and treatment recommendations. It is in fact already starting to being used in presurgical planning to map vital areas like languages, motor function, and memory.

The four main applications of MRI for functional information can be categorized as :-

1. BOLD-fMRI which measures regional differences in oxygenated blood.

2. Perfusion fMRI which measures regional cerebral blood flow.

3. Diffusion-weighted fMRI which measures random movement of water molecules and

4. MRI spectroscopy, which can measure certain cerebral metabolites noninvasively.

1. BOLD-fMRI (Blood-Oxygen-Level-Dependent fMRI)

BOLD-fMRI is currently the most common fMRI technique

With this technique, it is assumed that an area is relatively more active when it has more oxygenated blood compared to another point in time. This is based on the principle that when a brain region is being used, arterial oxygenated blood will redistribute and increase to this area. This principle has one limitation: there is a time lag of 3-6 seconds between when brain region is activated and blood flow increases to it . During this time lag of 3-6 second, in fact, the activated areas experience relative decrease in oxygenated blood as oxygen is extracted by the active regional neurons. Afterward, the amount of blood flowing to the area far out weighs the amount of oxygen that is extracted so that oxygenated blood is now higher. Although images can be acquired every 100 msecs with echoplanar (a type of rapid acquisition) BOLD fMRI, this predictable but time varied delayed onset of the BOLD response limits the immediate temporal resolution to several seconds instead of the 100 msec potential. In the future, researchers may be able to improve the temporal resolution of fMRI by measuring the initial decrease in oxygenated blood with activation.

BOLD fMRI is a relative technique in that it must compare images taken during one mental state to another to create a meaningful picture. As images are acquired very rapidly (ie. a set of 15 coronal brain slices every 3 seconds is commonly) one can acquire enough images to measure the relative differences between two states to perform a statistical analysis within a single individual. Ideally, these states would differ in only one aspect so that everything is controlled for except the behavior in question.

BOLD fMRI paradigms generally have several periods of rest alternating with several periods of activation. Images are then compared over the entire activation to the rest periods. Images obtained over the first 3 to 6 seconds of each period are generally discarded due to the delay in hemodynamic response. Alternating paradigms are used because the signal intensity generated by the MRI scanner drifts with time.

fMRI BOLD is best used for studying processes that can be rapidly turned on and off like language, vision, movement, hearing and memory. The study of emotion is hampered by its slow and variable onset and its inability to be quickly reversed. Some have, however, succeeded in using this technique to study emotional processes.

BOLD fMRI is very sensitive to movement so that tasks are limited to those without head movement, including speaking. BOLD fMRI is also limited in that artifacts are often present in brain regions that are close to air (ie. sinuses). Thus there are some problems in observing important emotional regions at the base of the brain like the orbitofrontal and medial temporal cortices. Another problem is that sometimes observed areas of activation may be located more in areas near large draining veins rather than directly at a capillary bed near the site of neuronal activation. Neurologists and neurosurgeons are beginning to use this technique clinically to noninvasively map language, motor and memory function in patients undergoing neurosurgery.

Two fMRI methods have been developed for measuring cerebral blood flow. The first method, called intravenous bolus tracking, relies on the intravenous (iv) injection of a magnetic compound such as a gadolinium-containing contrast agent and measuring its T2 weighted signal as it perfuses through the brain over a short time period of time.

Areas perfused with the magnetic compound show less signal intensity as the compound creates a magnetic inhomogeneity that decreases the T2 signal. The magnetic compound may be injected once during the control and once during the activation task and relative differences in blood flow between the two states may be determined to develop a perfusion image. Alternatively one can measure changes in blood few over time over time after a single injection to generate a perfusion map.

Although gadolinium-based contrasts are not radioactive, the number of boluses that can be given to an individual is limited by the potential for kidney toxicity with repeated tracer administration. This technique also only generates a map of relative cerebral blood flow, not absolute flow as in the text technique. Arterial spin labeling is a T1 weighted noninvasive technique where intrinsic hydrogen atoms in arterial water outside of the slice of interest are magnetically tagged (“flipped”) as they course through the blood and are then imaged as they enter the slice of interest.

Arterial spin labelling is noninvasive, does not involve an IV bolus injection, and can, thus, be repeatedly performed in individual subjects. Also, absolute regional blood flow can be measured which cannot be easily measured with SPECT or BOLD fMRI and requires an arterial line with PET. As absolute information is obtained, cerebral blood flow can be serially measured over separate imaging sessions such as measuring blood flow in bipolar subjects as they course through different disease states. Absolute blood flow information may be important in imaging such processes as anxiety which may be hard to turn on and off. For instance, in social phobics, a relaxation task may be imaged on one day and anticipating making a speech may be imaged on the next day. Comparing these separate tasks in different imaging sessions would not be possible with BOLD fMRI. Arterial spin labelling has some limitations in that it takes several minutes to acquire information on a single slice of interest. Therefore, one must have a specific brain region that one is interested in examining. Also, as it currently takes several minutes to acquire a single slice, it would be tedious obtaining enough images on this slice within a single session to make a statistical statement on a given subject.

2. Diffusion-Weighted Imaging (DWI)

Diffusion-weighted imaging is very sensitive to the random movement of 1 H in water molecules (Brownian movement). The amount of water diffusion for a given pixel can be calculated and is called the apparent diffusion coefficient (ADC). Areas with low ADC value (ie. low diffusion) appear more intense. ADC values are direction sensitive. For instance, if images are taken perpendicular to myelin fiber tracts like the optic chiasm, arcuate fasciculus, or corpus callosum, ADC values will be lower than if the images are taken along the length of these fibers. This is thought to because there is little diffusion across myelin sheaths. Thus, ADC direction sensitivity permits detection of Myelination and may allow researchers to understand in greater detail myelin development in infants. On the other hand, this direction sensitivity hampers the study of diffusion in other processes as ADC values differ, depending on the imaging plane (axial, coronal or sagittal). There are now ways to calculate average ADC values incorporating all planes for each pixel, removing “artifacts” due to the direction of acquisition. Removing the directional diffusion sensitivity has been helpful in studying stroke.

While it is currently unclear now diffusion-weighted imaging will be useful in studying psychiatric disorders, it hold great promise for changing the clinical management of acute ischaemic stroke by potentially refining the criteria for patients most likely to benefit from thrombolytic therapy.

3. MRI Spectroscopy (MRS):

MRI spectroscopy (MRS) offers the capability of using MRI to noninvasively study tissue biochemistry. In the conventional and functional MRI techniques listed. The hydrogen atom in water is the main one that is flipped (resonated). In MRS, either 1H atoms in other molecules or other atoms such as 31P, 23Na, K, 19F or Li are flipped. Within a given brain region called a voxel, information on these molecules is usually presented as a spectrograph with precession frequency on the x-axis revealing the identity of a compound and intensity on the y-axis, which helps quantify the amount of a substance. The quantity of a substance is related is related to the area under its spectrographic peak; the larger the area, the more of a substance that is present.

The reason why several molecules can be identified and quantified within a single scan is that the resonant magnetic pulse has a bandwidth over a narrow precession frequency range os that it can flip several molecules at once. The signal intensity at each of these precession frequencies can then be identified using a complicated mathematical procedure called a Fourier transform. For a given precession frequency (or spectrographic peak of a given molecule), information can also be presented spatially as metabolic maps which are created with similar principles to the 1H atom in water spatial map in conventional MRI. The spatial resolution of these maps is generally less than that of conventional MRI as the substance concentration is much less than that of water. Consequently, the minimum area needed to obtain a visible signal is greater.

The two most widely used MRS techniques involve either viewing 1H atoms in molecules other than water or 31P-containing molecules. In 1H MRS, the water signal must first be suppressed as it is much greater than the signal from other 1H-containing compounds and has overlapping spectroscopic peaks with compounds.

Compounds that can be resolved with 1H-MRS include:

a) N-acetylaspartate (NAA) which is though to be a neuronal marker that decreases in processes where neurons die;

b) Lactate which is a product of anaerobic metabolism and may indicate hypoxia;

c) Excitatory neurotransmitters glutamate and aspartate;

d) The inhibitory neurotransmitter gamma-amino butyric acid (GABA);

e) Cytosolic choline which includes primarily mobile molecules involved in phospholipid membrane metabolism but also small amounts of the neurotransmitter acetylcholine and its precursor choline;

1. Myolinositol which is important in phospholipoid metabolism and intracellular second messenger systems; and

2. Creatine molecules such as creatine and phosphocreatine which usually have relatively constant concentrations throughout the brain and are often used as relative reference molecules (ie. one may see NAA concentration reported as the ratio NAA/creatine in the literature).

Phosphorus (31P) MRS allows the quantification of ATP metabolism, intracellular pH, and phospholipid metabolism. Mobile phospholipid, including phosphomonoesters (PME – putative cell membrane building blocks) and phosphodiesters (PDE – putative cell membrane breakdown products) can also be measured, supplying information on phospholipid membrane metabolism.

MRS is an useful tool to be used in the characterization of tumor, stroke and epileptogenic tissue and in presurgical planning.

Limitations

MRS is restricted to studying mobile magnetic compounds. As neurochemical receptors are noted usually mobile, they cannot be measured with MRS. Thus, receptor-ligand studies in psychiatry are still the domain of SPECT and PET. Another problem with MRS is that due to the low concentrations of many of the imaged substances, larger areas than with water are needed to obtain detectable signals. Larger volume units imaged over longer periods are thus used with this technique, limiting both temporal and spatial resolution compared with conventional MRI and BOLD-fMRI. However, stronger magnetic fields which can spread out precession frequencies over a wider range may improve this resolution.

Conclusions

While there are currently no clinical indications for ordering any of these fMRI techniques, they hold considerable promise for unraveling the neurocircuitry and metabolic pathways of numerous disorders in the immediate future and in further helping in diagnosis and treatment planning.

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radiation protection

Image gently…

Step Lightly

Interventional radiology helps us save kids’ lives!But, when we treat patients, radiation matters! Children are more sensitive to radiation. What we do now lasts their lifetimes. Treat kids with care:
Step lightly on the fluoroscopy pedal.
Stop and child-size the technique.
Consider ultrasound or, when applicable, MRI guidance.
Steps for Radiation Safety in Pediatric Interventional Radiology
Plan, prepare and communicate.
Measure, record and review.
1. Equipment
1. Qualified medical physicist (i.e., one who is board certified in diagnostic radiological physics) consultation at equipment selection,set up, and in equipment maintenance and quality assurance (QA).
2. At equipment set up, medical physicist to measure the radiation output from the interventional fluoroscope. Both the maximum radiation output (for largest adult-size patients) and routine radiation output as a function of varying patient size to be measured and documented.
3. At installation, “child-size” angiographic protocols created, with dose reduction, appropriate lengths of runs, and different frame rates for slow vs. high flow, infant, small child and teenager sized patients
4. CT guided procedures: “child size” protocols for CT guidance, using as low an mA as possible
5. Dose recording and reduction technologies installed in equipment
2. Pre procedure consultation
1. Ask about previous radiation
2. Answer questions about radiation safety

3. During procedure:
1. Appropriate communication between in room personnel: Don’t be afraid to ask the necessary questions to ensure you are working as a team to keep the radiation dose as low as possible
2. Use US if possible
3. Plan and communicate in advance: plan number of runs, injection parameters, contrast, pump, digital subtraction angiography (DSA) frame rates and optimize patient position timing with anesthesia and the
radiologist carefully, so as to avoid improper or aborted runs and the need to repeat a run.
4. Lower the number of exposures: use flouro save when possible.
5. View and save images with last image hold, decreasing acquisitions/exposures as much as possible when that level of detail is acceptable.
6. Step lightly: tap on pedal and examine still image on monitor, minimize live fluoroscopic time
7. Position with fluoroscopy off
8. Use pulse fluoroscopy when possible. Use a low pulse rate rather than high pulse rates or continuous fluoroscopy; for example, decrease from 7.5 pulses to 3 pulses a second whenever possible.
9. Collimate tightly. Decreasing the area of patient exposure directly decreases patient dose. Collimate to avoid dose to the eyes, thyroid and gonads whenever possible
10. Minimize overlap of fields in repeated acquisitions
11. Decrease the dose rate setting to the lowest level that provides adequate image quality during either fluoroscopy or the recording of images.
12. Minimize use of electronic magnification. Use fluoroscopic zoom whenever possible instead. Switch back to zero magnification whenever possible.
13. Move table away from x-ray tube in both planes to maximize distance between source and patient. Maintain an appropriate source to table top distance throughout the procedure. This shall be no less than 15 inches at any time. Lower the image intensifier (or flat panel detector) as close to the patient as possible, to minimize patient to detector distance, while still allowing room for manipulation of needles, wires catheters. Remember these principles in the lateral position.
14. Avoid radiosensitive areas (breast, eyes, thyroid, gonads) when possible. Evidence on the need/advisability for shielding of areas outside of the beam is conflicting at present.
15. Audible periodic fluoroscopy time alerts during case. Acknowledge the cumulative timing device. A reminder of the elapsed fluoroscopy time can be given to the operator during the procedure.
16. Image acquisition limited only to needed (frames per second, lower dose protocols, magnification, length of run)
4. After procedure:
1. Review dose
2. Counsel if skin dose greater than or equal to 2 Gy or cumulative dose of greater than or equal to 3 Gy (NCI)
5. Education
1. All operators receive comprehensive training in radiation physics, biological effects and safety.
2. Ongoing yearly training after initial certification
3. Audit radiation doses for all operators
4. Specific feedback and additional training when needed
5. All operators and team members, including non-radiology users betaught, tested and credentialed in radiation physics principles,radiation biology and radiation safety.
6. Measurement and QA
1. Record available indications of patient radiation dose including DAP,cumulative air kerma, etc. If these indices of radiation dose are notavailable, record fluoroscopy time and an estimate of the total number of recorded images, so that patient dose could be estimated in the future if necessary.
2. Patient dose record (Medical Imaging Record)
3. QA measures: Participate in or support radiation awareness undertakings in your department
4. In house radiation dose database of patients, procedures and dose information
5. Review radiation dose database to flag patients with doses greater than 2 Gy for follow up
1. Notes to primary care physician about procedure, dose and possible short and long term effects.
2. Counsel patient and primary care to call if erythema develops at beam entrance site
3. Establish follow up procedures including skin examination at 30 days
4. Minimize cumulative dose over time for radiology operator and staff
1. Remember that reducing patient dose reduces scatter and dose to personnel also: they are tied together
2. Personal protective equipment:
1. Leaded eyewear
2. Well fitted lead apron
3. Thyroid shield
3. Use hanging lead shields to protect lower extremities and movable overhead shields for face and neck protection. Set up the room at the start of the case with lead table skirts and all shielding. Don’t be hesitant to remind the operator of their use.
4. When using lateral fluoroscopy, position personnel on same side as the image receptor/detector to decrease operator scatter dose from X-ray source
5. Step away during fluoroscopy or image acquisition if possible
6. Operator hands out of beam
7. Use power injector when possible. If hand injection, use extension tubing.
8. Distance: Advise the personnel in the room of the inverse square law (nurses, anesthesia, physicians)

Step Lightly Checklist
Review steps below before starting the procedure.
Safety is a team effort: don’t be afraid to ask the necessary questions to ensure you are working as a team to keep radiation dose to patients and staff as low as possible.
Reducing radiation dose must be balanced with safe, accurate and effective completion of the procedure. Not all the steps below may be possible in each case, depending on patient size, technical challenge and critical nature of the procedure. Overall patient safety is most important. The goal is to minimize the dose to the patient while providing important and necessary medical care.
• Ask patient or family about previous radiation (record card downloadable at this link). Answer questions about radiation safety (parent/patient brochure downloadable here)
• Use ultrasound when possible
• Position hanging table shields and overhead lead shields prior to procedure with reminders during the case as needed
• Operators and personnel wear well fitted lead aprons, thyroid shield and leaded eye wear
• Use pulse rather than continuous fluoroscopy when possible, and with as low a pulse as possible
• Position and collimate with fluoroscopy off, tapping on the pedal to check position
• Collimate tightly. Exclude eyes, thyroid, breast, gonads when possible
• Operator and personnel hands out of beam
• Step lightly: tap on pedal and review anatomy on last image hold rather than with live fluoroscopy when possible; minimize live fluoroscopy time
• Minimize use of electronic magnification; use digital zoom whenever possible
• Acknowledge fluoroscopy timing alerts during procedure
• Use last image hold whenever possible instead of exposures
• Adjust acquisition parameters to achieve lowest dose necessary to accomplish procedure: use lowest dose protocol possible for patient size,lower frame rate, minimize magnification, reduce length of run
• Plan and communicate number and timing of acquisitions, contrast parameters, patient positioning and suspension of respiration with radiology and sedation team in advance to minimize improper or unneeded runs
• Move table away from X-ray tube in both planes. Move patient as close to detector in both planes
• Use power injector or extension tubing if hand injecting
• Move personnel away from table or behind protective shields during acquisitions
• Minimize overlap of fields on subsequent acquisitions
• After procedure: record and review dose
Frequently Asked Questions – Medical Professionals
The amount of radiation that people are receiving from medical sources is increasing, and this includes children. It is difficult to show directly that radiation doses from CT lead directly to cancer. However, good data from other sources of exposure show that there are increased cancers in people who have been exposed to radiation at levels now encountered by patients undergoing CT scans. This is particularly important in children, whose tissues are more radiosensitive, who receive a larger effective dose for a given level of radiation, and who have a longer time to develop cancers resulting from radiation exposure. For any one person, the risk of death from cancer is about 1 in 5. While estimates vary, for a child undergoing a single CT of the abdomen and pelvis increases that risk by 1 in 1,000. The risk is cumulative, however, and each subsequent CT scan will increase the risk accordingly. While for any one individual the increased risk is very small, given the large number of CT scans performed the risk to the population as a whole is much larger.
Do children really undergo many CT scans?
The population of the United States is second only to Japan in per capita CT exams performed. There are approximately 7 million CT studies performed in children every year in the United States, and the number is increasing approximately 10% per year. CT is widely used among all ages of children, with 33% performed in children under 10 years of age. CT is the largest contributor to medical radiation dose in the United States.
Can the risk from CT be lessened while still obtaining diagnostic quality studies?
* Absolutely. There are many techniques that can be used to dramatically lessen the amount of radiation children are exposed to during CT, while still enabling diagnostic quality images (see also What Can I Do? Section). These include:
o Scan only the area required. Scanning beyond the body regions where there is clinical concern results in needless exposure.
o Reduce tube output (kVp and mAS). Exposure parameters should be reduced for the smaller patient size. A number of suggested protocols are available (LINK)
oPerform single phase studies. Most pediatric conditions are readily diagnosable with single phase CT; more phases unnecessarily increases radiation dose without adding to diagnoses.
oUse breast shields for girls undergoing chest CT studies.
Should I not order CT scans for my pediatric patients?
CT is an extremely useful imaging modality that can provide valuable and even life-saving medical information, and thus can provide more benefit than harm. Like any test, there should be clear reasons to order a CT scan. For many indications, a test like ultrasound or magnetic resonance imaging may provide the same information without exposing a child to radiation. The American College of Radiology (ACR) has imaging appropriateness criteria for a number of pediatric conditions and discusses the utility of various imaging strategies. Discussing the clinical situation and the medical information desired with the pediatric radiologists providing your imaging services can help determine if an alternative test might be better. If a CT scan is needed, make sure that your imaging facility uses appropriate radiation reduction protocols and techniques, and that those interpreting these pediatric studies are qualified.

How can I determine if my imaging providers are using appropriate CT techniques?
Without asking, you won’t know. Some facilities may not alter dose technique for studies on children. This website has published a straightforward method that can be implemented at your site with the help of a medical physicist. It is unique in that it does not depend on the manufacturer, model or age of the scanner. While there may be variability depending upon CT scanner manufacturer and institution, there are also a number of published suggested techniques that facilities can use that provide substantial dose savings. Similarly, most adult protocols call for scanning the same area several times (multiple phases); this is rarely required for pediatric conditions and results in needless additional radiation exposure.
Ask:
o if your imaging facility is accredited .
o if the CT technologists are credentialed
o if a board certified radiologist or pediatric radiologist will
be interpreting the study
Should I talk to parents about the risks involved in getting a CT?
The long-term risks of exposure to medical radiation are small but real. However, the diagnostic value that a CT can provide in the short-term usually far outweighs the long-term risks. Most patients are not informed of any potential risks from radiation prior to the exam (Lee CI, et al. Diagnostic CT scans: assessment of patient, physician and radiologist awareness of radiation dose and possible risk. Radiology 2004;231:393-398), although some institutions are requiring patient informed consent prior to undergoing CT. While it seems like this would deter patients from getting potentially important exams performed, a recent research study found that parents who were told about the risks and benefits of CT still agreed to go ahead and have the study performed (Larson DB, et al. Informing parents about CT radiation exposure in children: it’s OK to tell them. AJR 2007;189:271-275). In short, you should not hesitate to discuss the potential risks of CT radiation with patients and families.

Where can I find guidelines/protocols for pediatric CT?
Return to the “What can I Do?” section of this website for specific suggestions and guidelines for every member of the Imaging team including protocol recommendations.

Fwd: regarding attending 35th radiology conference…

———- Forwarded message ———-
From: k n sharma <dockns@gmail.com>
Date: Tue, Aug 25, 2009 at 5:53 PM
Subject: Re: regarding attending 35th radiology conference…
To: drhsdas@gmail.com

thanx for  reply sir…. i m Dr k n sharma from sikkim and dr ray is  from tripura.. we are both pursuing md radiology course.. congritulation for your good articles on your websites  all those radiology articles are world standard… article of PNS and FESS was beautiful……. thanx again..bye

On Mon, Aug 24, 2009 at 9:35 PM, himadri das <drhsdas@gmail.com> wrote:

 dear Dr(s) Sharma & Ray,
 
greetings. Thank you for your mail.Our work is progressing very well & i will let you know by next week. Are you all pursuing radiology MD course?
 
Dr Himadri

Fwd: Three MRI Images with gadolinium

———- Forwarded message ———-
From: himadri das <drhsdas@gmail.com>
Date: Fri, Dec 5, 2008 at 7:21 PM
Subject: Re: Three MRI Images with gadolinium
To: Lenny & Lynne Camera <ljjc@verizon.net>

Hi,

As regards to your mail , I dont know whether I shuold be answering this but anyways- every things to be correlated with history, signs , symptoms & actual temporal cascade of events leading the patient to to CT or MR suites.My off the record & personal observations would be:

E5: Yes could be cortical venous thrombosis and/or focal cerebritis. Infection from the left frontal sinus will however have to pierce the bones & the dura so few CT sections might help.

28: mild bilateral maxillary sinus disease. however the airspaces of the nasal cavities are reduced due to DNS & hypertrophied turbinates leading to nasal blockage ( if any ) compounding the sinus disease. The sinus ostia ( OMU) shuld be observed to see whether patency is maintained.

43: I feel its bilateral maxillary mucosal thickening with polypoidal component anteriorly on the right side.

Regards & best wishes,
Dr H.S.Das


On Thu, Dec 4, 2008 at 8:10 PM, Lenny & Lynne Camera <ljjc@verizon.net> wrote:
Can you explain what you see in these three images. The first image 14B68928, December 24, 2007…..is this case of sinusitis/maxillary disease considered severe? On Second image 051FEFE5 Question…….could the cloudy white spot in the upper left frontal be an abscess from the sinuses? On Image 041A7943 and 14B68929 could it be not totally sinusitis, could some of it be pooling from a small CSF leak due to trauma?
Thank you

Lumbarization or sacralization-?. Concept of lumbosacral transitional vertebra

Lumbarization or sacralization-?. Concept of lumbosacral transitional vertebra by MRI

Lumbosacral transitional vertebrae (LSTV) occur when the last lumbar vertebra shows elongation of its transverse process, with varying degrees of fusion to the first sacral segment. The term “LSTV” is used to avoid having to decide whether such a vertebra is a “sacralized L5″ or a “lumbarized S1.” Although LSTV can be sensitively identified on sagittal lumbar spine MRI, based on abnormal morphology of the lumbosacral junction  no standard method is established for their numbering. Techniques that have been used include the addition of cervicothoracic localizer scans and determining lumbar levels by identification of the right renal artery(in relation to the L1-2 disk space ). These techniques are prone to substantial error.Both anatomic and MRI studies have indicated that the iliolumbar ligament (ILL) arises almost exclusively from the L5 transverse process  However, these studies are limited by relatively small numbers  .if ILLs can be reliably identified on routine axial MR images through thelumbosacral junction and if they arise solely from L5, then their level of origin can serve as a marker of lumbar levels, which may enable the confident numbering of LSTV.
The ILLsappear as either a single or a double hypointense band arising from the transverse process and extending to the posteromedial aspect of the iliac crest.  If an LSTV is present, it is numbered as a transitional L5 or transitional S1 segment based on the following method. When the ILL  arises at
the level above the LSTV, the vertebral level of origin of the ILL was labeled L5 and, consequently, the LSTV was numbered S1 . If the ILL is not visualized, the LSTV is numbered L5  This numbering system was based on the hypothesis that in the presence of healthy lumbosacral segmentation, the ILL always arises from L5

and is therefore a marker of the L5 level.

Using identification of the iliolumbar ligaments as a marker of the L5 vertebral level, we can number LSTV as L5 transitions and S1 transitions. The iliolumbar ligament is readilyidentifiable on axial lumbar spine MRI and always arises from L5.We suggest that its position can be used to confidently assign lumbar levels in patientswith LSTV.

Unusual MR presentations of Pyogenic Spondylodiscitis –

tb-spine-photo

Unusual MR presentations of Pyogenic Spondylodiscitis –

H.S.Das N. Medhi, P.Sarma, P.Goswami, , P.Hazarika.

Infective (Pyogenic and tubercular) spondylitis is a relatively common entity in day-to-day practice. Though commonest cause of such infection is tuberculosis in our country, pyogenic infection of the spine is also frequently encountered. Majority of these pyogenic infections of the spine are iatrogenic in nature, though in some cases the cause and source of infection cannot be ascertained. We report 4 patients of infective spondylodiscitis with unusual presentations.

Case-1: 43 yrs female patient had laparoscopic cholecystectomy in a local hospital. She was nondiabetic and nonhypertensive and blood examination revealed mild anemia and slight rise in the TSH. After surgery was uneventful and she was kept in the intensive care unit overnight and sent to the paying ward after 24 yrs. Her immediate postoperative status was perfectly all right. On 2nd postoperative night she developed excruciating pain and she got partial relief of pain after putting her on continuous parenteral analgesics. Though her pain remained unaltered she was discharged on the 4th day only with analgesics. As pain did not subside an MR examination of the cervical spine was performed. MRI showed significant loss of cervical lordosis with hazy epidural space and provisionally the treatment was continued as cervical sprain. She continued to have pain and later on she developed difficulty in lifting the head. Second MR was performed on 3rd week due to detorioration of her condition and showed evidence of spondylodiscitis at C5-C6 level. She was provisionally put on antibiotics (amikacin 500 mg iv x2weeks followed orally for 6weeks).

Case no 2. 35 yrs old patient had tonsillectomy for chronic tonsillitis. The surgery was carried under general anaesthesia and it was uneventful as far as the primary disease is concerned. He was non-diabetic and nonhypertensive. On third postoperative day the patient developed severe pain in the neck with out significant radicular pain. He was discharged from the hospital with simple analgesic without significant improvement in the condition of the neck pain. As patient deteriorates further an MR examination was performed. MR study reveals involvement of the C5-C6 disc by T2 hyperintense collection, marrow edema involving C5 and C6 vertebral bodies, prevertebral and epidural soft tissue collection. Due to significant compression of the cord surgery was performed to relive the compression and to get a histological diagnosis. At surgery the involved bones were very soft and infected material was removed from the site. Bacteriological and histological diagnosis was pyogenic infection and culture shows growth of pseudomonas infection. The organisms were sensitive to amikacin and gentamycin. Patient improved after surgery.

Case. No 3: 28 yrs female patient had CS under GA. The patient was not diabetic and nonhypertensive. Her pre operative blood and other laboratory parameters were grossly normal. The patient developed severe pain in the neck on 3rd postoperative day. She was also managed by rest and analgesics thinking it to be cervical spondylosis. As her status remains same in spite of rest and analgesics she was investigated by cervical MR. The MR showed features of spondylodiscitis at C5-C6 level with significant thecal compression by the epidural soft tissue component. There was prevertebral abscess also. As her condition continues to deteriorates decompressive surgery was performed. At surgery thick pus with granulation tissue was removed and sent for biopsy and bacteriological study. At pathology features were suggestive of pyogenic spondylodiscitis with salmonella infection. The organisms were sensitive to ciprofloxacin group of antibiotics and not very sensitive to the amikacin and gentamycin. She was put on parenteral antibiotics for 2weeks followed by oral antibiotics for 6weeks. She was completely free from all symptoms.

Case 4: 30 yrs female patient had undergone CS operation. She developed severe pain in the neck on third day of her surgery. Though she was treated with neck exercise and analgesic she continued to deteroriorate and an MR examination was called for. MR study of the cervical spine reveals evidence of spondylodiscitis at C5-C6 vertebral body with epidural and prevertebral collection with mild cord impingement. She was treated was lost to follow up.

Important observations:

- All the patients were operated in the same hospital.

- All 4 patients were operated within the month of June and July. No such patients were reported before or after this period.

- The surgeons were different in all of the cases.

- All patients had involvement of the C5-C6 levels.

- Clinical presentation and course of the disease were almost similar.

Discussion:

Spondylitis is a condition where there is primary infection of the vertebral body. Disc space involvement is called discitis. Pure vertebral osteomyelitis or discitis is infrequent and most of the time there is involvement of both vertebrae and disc hence term spondylodiscitis is preferred. The third element of the spinal infection is the epidural abscess, which is also frequently associated with spondylodiscitis.

Types of spondylodiscitis: According to the offending organism the spondylodiscitis may be pyogenic or Tubercular, though rarely other organisms like Brucella, Fungal or parasites may cause spondylodiscitis.

Pyogenic spondylodiscitis
Pyogenic infection of the spine can occur by three routes- hematogenous spread, direct inoculation and contiguous spread.

Though apparent source of infection in a patient with spondylodiscitis can not be traced even after through check up in most of the patients, the common source of hematogenous spread is from infections of the urinary tract, lungs, pelvis and skin. IV injections may be the source of infection in some patients developing spondylodiscitis after surgery. In diabetics and immuno-compromised patients, a spinal infection is relatively more frequent. The disc is directly infected in children in hematogenous route due to persistence of peridiscal blood vessels. But in adult the disc is avascular and is secondarily affected.

Pyogenic spondylodiscitis can occur by direct inoculation of the disc or contiguous spread of infection. A major proportion of this type of infection is iatrogenic. Iatrogenic disc space infection is most commonly encountered following spinal surgery. This is true in our experience also, where majority of pyogenic spondylodiscitis is due to lumbar disc surgery. This is due to various factors -firstly the lumbar disc surgeries are relatively common; secondly UTI and other pelvic infections frequently involve the lumbar spine. Majority of pyogenic infections are due to staphylococcus aureus and enterobacter group. Other organisms causing pyogenic spondylodiscitis are salmonella and serratia etc.

MR findings- MRI is the single most valuable imaging technique in evaluation of pyogenic spondylodiscitis. MRI can pick up the changes at the earliest stage so that these patients can be treated soon and hence the morbidity is significantly reduced. Involved vertebral bodies reveal increased signal intensity on T2 weighted images and reduced signal intensity on T1 weighted images due to marrow edema. The intervertebral disc reveal reduced signal intensity on T1 weighted images and strong / very strong signal intensity on T2 weighted images sometimes called “hot disc”. There is irregularity in the vertebral end plates with destruction sometimes.
In more advanced cases there is progressive destruction of the vertebral bodies. There is prevertebral soft tissue and epidural lesions in advanced cases.

Tubercular Spondylodiscitis: TB spondylodiscitis most commonly occurs by hematogenous route and generally affects all age groups. The vertebral body is primarily involved with secondary involvement of the appendages, disc and epidural space. There may be involvement of the cord also producing intra-medullary tuberculoma. Lower thoracic and upper lumbar vertebrae are more commonly affected.

MRI findings MR usually pick up the findings very early. There is involvement of two contiguous vertebral bodies including the disc. Involvement of more than two vertebral bodies and areas of skip lesions are frequently encountered. The involved vertebral bodies reveal reduced signal intensity on T1 weighted images and appear iso to hyperintense on T1 weighted images. There is involvement of the posterior elements and lot of epidural granulation tissue or frank collection is seen. Arachnoiditis and intra-medullary tuberculomas may be found.

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MR findings of TB Vs Pyogenic spondylodiscitis

  1. Disc space involvement is common in pyogenic infection. The disc becomes hyperintense on T2 weighted images classically described as “hot disc”.
  2. In tubercular infection the posterior elements are also involved which is uncommon in hematogenous pyogenic infection.
  3. More than two vertebral body segments are frequent in TB and there are skip lesions in some cases.
  4. Epidural space, spinal meninges and cord involvement more frequent in TB than pyogenic infection.

Other infections:

Other uncommon causes of spondylodiscitis are Brucella, fungal and rarely parasitic. Brucella spondylitis is characterized by erosion of the anterior aspect of the superior end plate. There is significant sclerosis along with lytic lesions. In fungal spondylitis the responsible organisms are blastomycosis, cryptococcosis and coccidiomycosis. There are destructive lesions, paravertebral soft tissue mass, multiple sites of involvement and relative sparing of the disc are some of the features of fungal spondylodiscitis.

Conclusion: MRI plays a vital role in diagnosis and management of spondylodiscitis. It has highest sensitivity in diagnosis such cases, where it can characterize most of these patients. Unusual presentation of infective spondylitis may cause confusion in diagnosis; FNAC or biopsy may be necessary in some of these patients. Difficulties may arise in differentiating spondylodiscitis with type-1 end plate change, where contrast study may be helpful. Similar problems may arise in cases where infection co-exists in pre existing tumor, where biopsy will give the final diagnosis.

BRIEF REVIEW OF PULMONARY IMAGING IN CRITICALLY ILL PATIENTS:-

BRIEF REVIEW OF PULMONARY IMAGING IN CRITICALLY ILL PATIENTS:-

Dr Himadri S. Das

Matrix, Guwahati

Imaging plays an important role in assessment and daily management of acute life threatening conditions in critically ill patients with multi-systemic involvement. Modalities which are used for primarily for pulmonary imaging include x-rays (mostly using portable equipment with low mA), USG (using portable bedside units), transesophageal Doppler and CT scans. The availability of multislice CT scanners has reduced the problem of breath holding and patient motion with faster imaging times. Most of the critically ill patients usually can not obey commands, can not hold breath or be properly positioned and above all are under life support systems or ventilated with numerous tubes, catheters and lines .Role of Imaging is increasing in the intensive care setting. A brief review pertaining to pulmonary imaging in critically ill patients is outlined below.

Normal tubes, lines and catheters: Radiography should be done after insertion of tube or line to see correct position and identify complications. Iatrogenic problems from malpositioned lines are common and may be life threatening.

Normal findings:-

  1. Endotracheal tube (ET) – Normal ET tube tip should be 3 to 5 cm above carina. In neutral head and neck position the tube is seen 3 to 5 cm above carina. If the cervical spine is flexed the ET tube may descend 2 cm so the tube tip is seen at 3 to 5 cm from carina. If the cervical spine is extended there is 2 cm ascent of the tube tip which is seen 7 to 9 cm from carina. Ideally the tube width should be at least 2/3rd of the width of trachea. The cuff of the tube should not bulge the tracheal wall.
  2. Nasogastric (NG / feeding) Tube: – For suction of fluid in supine position proper location of tip should be in fundus of stomach. For suction of air in supine position proper location should be in antrum of stomach.
  3. Tracheostomy tube: – For patients requiring long term intubation. Tube tip should be above carina. Tube width should be 2/3rd the width of trachea.
  4. Chest tube: – For pneumothorax in supine patient, the tube should be placed antero-superiorly ideally. For hydrothorax in supine patient the tube should be placed postero-inferiorly. For empyema and haemothorax CT may help to plan drainage. Early drainage is important. Poor drainage will lead to fibrothorax and patients may require decortication.
  5. Central venous catheter (central line):- To maintain optimal blood volume or long term drug administration. Ideal position is in distal SVC. Access may be obtained from internal jugular, antecubital or femoral veins.
  6. Swan Ganz catheter: – To measure pulmonary capillary wedge pressure. Reflects LA and LV end diastolic volume. Ideal position is in the right or left pulmonary artery. Same access as above.
  7. Surgically implanted catheters: - For long term venous access usually for antibiotics or chemotherapy. Reservoir is placed in anterior chest wall soft tissues. Catheter tip ideally in distal SVC.

Abnormal tubes, lines and catheter’s:- CT may be helpful when complications are suspected.

a) Endotracheal tubes :- (a) Malposition: – May be intubated into right mainstem bronchus causing atelectasis of left lung. Bronchus intermedius intubation may cause atelectasis of left lung and right upper lobe. If there is 100 % inspired oxygen there may be immediate atelectasis with bronchial occlusion.

a) Esophageal intubation: – may cause dilated stomach with poor lung volumes.

b) Vocal cord injury if tip is at the level of larynx.

c) Sinusitis with nasotracheal intubation.

d) Barotrauma: – Alveoli are over distended and may rupture from high peak pressure with mechanical ventilation. Others: – Interstitial emphysema, pneumomediastinum and or pneumothorax.

e) Aspiration pneumonia: – 5 to 10 ml of fluid may pool above the ET cuff. Deflation and aspiration may potentially develop into pneumonia. Suspected if normal air above cuff is replaced by soft tissue density.

f) Tracheostenosis: – Late complication. At stoma, tip or multiple foci. At tip usually occurs 1.5 cm below stoma.

g) Tracheomalacia: – Late complication.

b) Tracheostomy Tube: – Cuff may be in subcutaneous tissues with tissue necrosis. Over inflation of cuff or deflection of tip may lead to tracheoesophageal fistula or into artery or vein producing haemorrhage.

c) Nasogastric tube: – Into bronchus, lung or pleura. Signs: – Consolidation occurs if fluid is administered. Atelectasis if occluding air way and pneumothorax if penetrating lung.

d) Chest tubes: Poor position and inadequate drainage if tube is in the interlobar fissures. If in the chest wall the outer wall of the chest tube is not visible. If in the lung may cause bronchopleural fistula. Side hole in chest wall may cause massive subcutaneous emphysema. The tube tip impacting artery (example – Subclavian) or esophagus may result in injury / erosion.

e) Central venous catheter: (a). Malposition: – Into Subclavian, aorta or femoral artery. Through vein wall into pleura or mediastinum. Into myocardium or pericardium. Retrograde into a jugular vein, rarely into liver.

(b). Pneumothorax, mediastinal haematoma after placement.

(c). Catheter break and embolism. Aseptic or septic thrombus on catheter with pulmonary embolization.

(d). Fibrin sheath occlusion.

(e). Thrombosis of vein: – Directly related to period of catheterization and potential source for pulmonary emboli.

f) Swan Ganz catheter:-pulmonary infarction from wedged catheter with of without clot, and with or without inflated balloon tip. Arrhythmias may occur if tip is in right ventricle. Pulmonary artery pseudo aneurysm formation or rupture due to over distension of cuff in small pulmonary artery. Pseudo aneurysm is manifested as elliptical pulmonary nodule the long axis of which parallels the vasculature within 2 cm of hila, usually on right side. Pulmonary haemorrhage may occur if aneurysm ruptures.

g) Surgically implanted catheters: – Infection, septic emboli, thrombosis or torn catheter between clavicle and 1st rib felt as “osseous pinch”. Rotation of pulse unit in the soft tissues by the patient causing fracture or shortening of pacer lead ( twiddling sign )

Clinical issues and treatment:-

- Infected catheter may clear with antibiotic treatment without removal.

- Fibrin sheath-infuse tissue plasminogen activator, if unsuccessful then exchange catheter.

- Interventional snare retrieval for embolized catheter fragments.

- Infection most common complication of central venous catheter, usually staphylococcus.

- Fibrin sheath sign: – Catheter may be flushed but not aspirated.

DIFFUSE ALVEOLAR DAMAGE (DAD)

  • Diffuse peripheral pulmonary consolidation.
  • Lack of Kerley B lines and peribronchial cuffing.
  • Anterior (nondependent) cysts from barotraumas with positive end expiratory pressure (PEEP).
  • Acute respiratory distress syndrome (ARDS): Clinical definition, severe hypoxemia on high concentrations of O2, normal wedge pressure.
  • Seen with nearly any medical or surgical condition: Toxic fumes, aspiration, shock, postoperative, pancreatitis.
  • Pathophsiology : Inflammatory mediators damage capillary membrane
  • Etiology:
    • Nearly any major medical or surgical condition
      • Airway insult; aspiration (especially gastric acid); toxic fume inhalation; o2 toxicity; pneumonia.
      • Blood-borne insult; sepsis; transfusion; surgery; shock; eclampsia; pancreatitis.

Imaging Findings;

  • Best clue: Intubated patient with diffuse peripheral consolidation.

CXR:

  • Diffuse pulmonary consolidation.
  • Favors the lung periphery.
  • Kerley B lines infrequent (more frequent with cardiogenic edema)
  • Peribronchial cuffing infrequent.
  • Normal heart size: No pulmonary vascular redistribution.
  • May have small pleural effusions.
  • Initial use of PEEP may increase lung volume giving apparent radiographic “improvement”.
  • Barotraumas common with PEEP.
  • Superimposed pneumonia common.

CT / HRCT Findings.

  • Surprisingly inhomogenous.
  • Gravitational gradient: Ventral to dorsal increase in opacities.
  • Resolution, coarse reticular thickening and cyst formation in anterior (ventral, nondependent) lung.

Differential Diagnosis

General

  • Usually patients with ARDS rapidly intubated to support oxygenation even when severity of consolidation is mild. Rather than radiographic differentiation, clinical management based on Swan-Ganz catheter and pulmonary capillary wedge pressure (PCWP)

Cardiogenic Edema

  • Separation from cardiogenic pulmonary edema moderately successful. Absent Kerley B lines and peribronchial cuffing, peripheral predominance, Normal heart size, pleural effusions rare. No pulmonary vascular redistribution, normal vascular pedicle.

Pneumonia

  • May have identical radiographic findings, may result in ARDS.

Massive Aspiration

  • May have identical radiographic findings, may result in ARDS.

Hemorrhage

  • May have identical radiographic findings, patient often anemic

Clinical Presentation

  • Acute (immediate) or insidious (hours or days) after initiating event.
  • Dyspnea, tachypnea, dry cough, agitation, cyanosis.
  • ARDS clinical definition for ADA, PaO2 < 50 with F1O2 > 50%
  • Normal wedge pressure : Decreased lung compliance
  • May have no chest radiographic abnormalities in first 12 hours
  • Later, chest radiograph diffusely abnormal

Prognosis

  • High mortality rate
  • Survivors may have either restrictive or obstructive functional deficits.

ASPIRATION PNEUMONITIS:

  • Pulmonary inflammation due to aspiration of infected oropharyngeal secretions
  • Patients may be unconscious, post-operation, intubated or have gastro-esophageal disorders
  • Gravity-dependent opacities, usually bilateral, basal and perihilar
  • Recurrent pneumonias in chronic aspiration
  • Aspiration of gastric acid during labor and delivery can be server and fatal (Mendelson’s syndrome) Adults often have underlying conditions, e.g. neurologic disorders, alcoholism esophageal disorders, on mechanical ventilation, tracheoesophageal fistula

Imaging Findings

Best clue: Recurrent gravity-dependent opacities

CXR: Acute aspiration

o Gravity-dependent, patchy, multi-focal airspace opacities, usually bilateral (conversely may be unilateral) basal and peripheral

o Supine position; posterior segments of upper lobes or superior segments of lower lobes

o Airway findings from larger aspirated particles

§ Segmental or lobar atelectasis

§ Hyperinflation or air trapping more common in infants and children

o May worsen in first few days the clear rapidly

o Aspiration of large amounts of gastric common can progress to acute respiratory distress syndrome (ARDS)

o Complications: Necrotizing pneumonia, abscess, ARDS, pulmonary embolism.

  • Chronic aspiration
    • Recurrent opacities often in the same location, reticulonodular opacities, bronchiectasis, pulmonary fibrosis.

CT Findings

  • Airspace opacities in dependent lung, centrilobular nodules
  • Can be used to evaluate for complications of abscess, empyema

Differential Diagnosis

Pneumonia or Recurrent Pneumonias

  • Identical radiographic findings
  • Immunocompromised patient predisposed to recurrent pneumonias

Pulmonary Embolism

  • Identical radiographic findings
  • Infarcts peripheral, often with pleural effusion
  • Predisposing factors for thromboembolism

Pulmonary Edema

§ Cardiomegaly, pleural effusions

§ Kerley B lines uncommon with aspiration

AIDS

  • Identical radiographic findings
  • Aspiration predisposing factor for ARDS

Bronchiolitis Obliterans Organizing Pneumonia (BOOP)

  • Similar radiographic findings, may also wax and wane

Prognosis

  • Death rate for patients who develop ARDS from Mendelson’s syndrome is up to 50%.

ATELECTASIS (PULMONARY COLLAPSE):

  • Decrease in volume of lung or a portion of lung
  • Types : Obstructive, passive, cicatrizing and adhesive
  • Signs : Shift of fissures, mediastinum and hila toward collapse
  • Diagnosis can be made with chest radiography : CT to establish cause

Imaging Findings

  • Best clue : Displacement of fissures
  • Types of atelectasis
    • Obstructive, e.g. bronchial neoplasm, no air bronchograms
    • Passive e.g. pneumothorax or pleural effusion – lung volume loss in proportion to volume of occupied pleura space
    • Cicatrizing e.g. remote tuberculosis with volume loss due to scarring
    • Adhesive, e.g. ARDS collapse due to surfactant deficiency

  • Lobar Collapse
    • Airlessness of affected lobe, local increase in opacity
    • Total lung volume average = 6720 ml
    • Signs of atelectasis proportional to amount of volume loss
    • Crowding of vessels and bronchi in affected lobe
    • Displacement of fissures, mediastinum and hilum towards to collapse
    • Overinflation of remaining lobes
    • Silhouette” sign – loss of air – soft tissue interface when collapsed lung abuts an adjacent soft tissue structres

CXR:

  • Right upper lobe (RUL) atelectasis (average volume RUL = 1140 ml)
    • Collapses superiorly and medially, loss of SVC interface and apical soft tissue capping
    • PA – lateral radiograph : Minor fissure displaced upward
    • Lateral : Superior aspect of major fissure displaced anteriorly
    • Central mass : “Reverse S sign of Golden
    • Juxtaphrenic peak : Tent of diaphragm (due to upward retraction inferior accessory fissure)
  • Left upper lobe (LUL) atelectasis (average volume LUL = 1160 ml)
    • Collapses anteriorly, partial loss of left heart border, haze superimposed on left hilum
    • Lateral : Major fissure shifted anteriorly
    • Luftsichel sign : Superior segment of lower lobe causes a crescent lucency between the aortic arch and the atelectatic upper lobe
  • Right middle lobe (RML) atelectasis (average volume RML = 670 ml)
    • Collapses as a triangle toward the right heart border
    • PA : Obscuration of right heart border
    • Lateral : Thin triangle or pancake shape from anterior chest wall with apex towards hilum, inferior aspect of major fissure
  • Lower lobe atelectasis ( average volume LLL = 1550 ml, RLL 2000 ml)
    • Collapse posteriorly, medially and inferiorly
    • PA : Triangular opacity medial lung bases obscures diaphragms
    • Lateral : Posterior displacement of major fissure, vague opacity over lower thoracic spine
  • Right middle and lower lobe atelectasis
    • Similar to pleural effusion : Ill defined right heart border and diaphragm
    • Pathology involving bronchus intermedius
  • Right upper and right middle lobe atelectasis
    • Simulates left upper lobe atelectasis (double bronchus sign : 2 separate airways obstructed)
    • Borrie’s sump: Nodes between RUL and RML bronchus may obstruct both.
    • Bronchogenic carcinoma most common cause
  • Segmental and subsegmental atelectasis (plate atelectasis)
    • Long linear opacities are thicker and more indistinct than Kerley B lines
    • Indicates low volume states : common in critically ill or post-op-patients
    • Also seen with pulmonary embolism

  • Total lung atelectasis
    • Shift of mediastinum to opacity, hyperinflation of contralateral lung
    • Differentiating large pleural effusion : Mediastinal shift to opposite side
  • Round Atelectasis
    • Associated with pleural thickening (asbestos related) in lower lobes
    • Oval, wedge-shaped or irregular subpleural mass with air bronchograms (60%)
    • Comet tail sign (whorled bronchovascular markings into mass)
    • Most are stable for many years

CT Findings

  • Can help identify cause, i.e. bronchial obstructing lesion
  • No imaging can predict if the atelectatic lobe is sterile or infected
  • CT useful to exclude endobronchial lesion and confirm round atelectasis

Differential Diagnosis

Pneumonia

  • Radiographic opacity but no volume loss

Embolus

  • Peripheral opacity, volume loss of hemithorax due to splinting

Lung Cancer

  • Round atelectasis may simulate lung cancer
  • Endobronchial neoplasm common cause of lobar atelectasis in adult

General

  • Lobar obstruction, collapse in 18 to 24 hours if breathing room air
  • Lobar obstruction, collapse in < 5 minutes if breathing 100% oxygen
    • Nitrogen very slowly absorbed, delays development of atelectasis
  • Obstructed lobe may not collapse because of ventilation across the pores of kohn and canals of Lambert, or across incomplete fissures

Presentation

  • Asymptomatic fever can occur with atelectasis without infection
  • Left lower lobe collapse : Most common in ICU setting

CARDIOGENIC PULMONARY EDEMA

  • Common problem usually due to left heart failure
  • Stepwise progression from pulmonary venous hypertension to interstitial edema to alveolar edema.
  • Can clear rapidly with treatment.
  • Shifts gradually with position (gravitational shift test)

Imaging Findings

  • Best clue: Cardiomegaly with pulmonary venous hypertension and interstitial edema.

CXR:

  • Earliest radiographic manifestation: Upper lobe vessels are equal to or larger in diameter than lower lobe vessels; increased pulmonary artery / bronchus ratio in upper lobes, ill-defined lower lung vessels.
  • Interstitial edema – thickening of interlobular septa – Kerley A and B lines, lower zonal and perihilar haze, subpleural edema thickens interlobar fissures, peribronchial cuffing.
    • Kerley A : Long lines in upper lobes radiating towards hilum (rare)
    • Kerley B : Short, peripheral, perpendicular lines generally in lower lobes (common)
  • Alveolar edema – diffuse airspace opacification – gravity dependent
  • “Bat’s wing” (butterfly, perihilar) opacities (uncommon)
  • Small bilateral effusions, larger on right, rarely unilateral on the left
  • Cardiac enlargement chronically (normal heart with acute myocardial ischemia or arrhythmia)
  • In chronic obstructive pulmonary disease (COPD), the cardiac size is often small due to hyperinflation, subsequent increases in heart size may not be beyond the range of normal.
  • Azygos ± SVC distention (widened vascular pedicle)
  • Temporal relationship of pressure and volume
    • Acute pressure (capillary wedge pressure) elevation
      • Initially normal, edema accumulates over 12 hour period
    • Pressure decrease with treatment
      • Edema resolves hours to days; radiograph “lags” clinical course
  • Chest radiograph equivalents, smooth thickening of interlobular septa, bronchovascular bundle thickening, gravity-dependent ground-glass and / or airspace opacities.

Differential Diagnosis

Interstitial Edema: Pneumonia , Lymphangitic carcinomatosis

Alveolar Edema : Non cardiogenic edema, pneumonia , pulmonary hemorrhage

Alveolar proteinosis, acute eosinophillic pneumonia

Interstitial Edema, Cardiomegaly, Pleural Effusions

THE CHEST RADIOGRAPH FOLLOWING TRAUMA:

Soft tissues

Foreign bodies

Surgical emphysema

Ribs

Simple fracture May be associated with surgical emphysema, pneumothorax, extra- pleural haematoma or haemothorax. First rib fractures have a high incidence of other associated injuries.

Flail chest

Sternum:-

Fracture – May be associated with a clinically unsuspected dorsal spine fracture.

Sternoclavicular dislocation.

Clavicles and scapulae:-

Fracture – scapular fractures are usually associated with other bony or intrathoracic injuries.

Spine

Fracturewhen present, are multiple in 10 % and non-contiguous in 80% of these. Thoracic spine injuries have a much higher incidence of neurological deficit than cervical or lumbar spine injuries.

Cord trauma.

Nerve root trauma - especially to the brachial plexus.

Pleura

Pneumothoraxsimple (in 20-40 % of patients with penetrating injuries) or tension. Signs of a small pneumothorax on a supine chest radiograph include a deep costophrenic sulcus, basal hyperlucency, a “double” diaphragm, unusually clear definition of the right cardiophrenic angle or left cardiac apex and visualization of apical pericardial fat tags. CT is more sensitive than plain film radiography.

Haemothorax: in 25-50 % of patients with blunt chest trauma and 60-80 % of patients with penetrating wounds.

Lung

Contusion non-segmental alveolar opacities which resolve in a few days.

Haematoma – usually appears following resolution of contusion. Round, well-defined nodule. Resolution in several weeks.

Aspiration pneumonia.

Foreign body

Pulmonary oedemafollowing blast injuries or head injury (neurogenic oedema).

Adult respiratory distress syndrome (ARDS) widespread air space shadowing appearing 24-72 hours after injury.

Fat embolism

Trachea and bronchi

Laceration or fracture initially surgical emphysema and pneumomediastinum followed by collapse of the affected lung or lobe.

Diaphragm

Rupture – in 3-7 % pf patients with blunt and 6-46% of patients with penetrating thoraco-abdominal trauma. Diagnosis may be delayed months of year. Plain film finding include herniated stomach or bowel above the diaphragm, pleural effusion, a supra-diaphragmatic mass or a poorly visualized or abnormally contoured diaphragm. Probable equal incidence on both sides but rupture of the right hemidiaphragm is not so easily diagnosed.

IMAGING OF ICU PATIENTS FOLLOWING THORACIC SURGERY:

Median sternotomy:-

CABG is the most commonly performed operation. Valve replacement surgery comes next. Incidence of complications is low. Main complications are rebleeding and mediastinitis. In patients with rebleed 20% are picked up radiologically. Rebleeding usually occurs in first 24 hours. CT is the best modality to show complications like osteomyelitis, dehiscence, abscess and mediastinitis. Mortality is upto 50% with complications. Dehiscence or mediastinitis may be asymptomatic or present with nonspecific chest pain, cough and fever. Usually occur 10 to 14 days after operation.

Findings:-

CXR: – Immediate recovery room film, expected findings are – Basal atelectasis (90%), Left > Right due to phrenic nerve cooling, weight of heart and difficulty to suction left lower lobe bronchus.

Edema (mild):- Cardiopulmonary bypass “pump lung”, anesthetic volume expansion and intrinsic left ventricular dysfunction.

Mediastinal bleeding: - Initial recovery room film for baseline width, may normally increase in width in first 24 hrs.

Sternal dehiscence: – May be normal. Vertical sternotomy incision > 3 mm width. Wire fracture incidental finding and not a finding of dehiscence.

CT is the best modality to show sternal irregularity, periosteal new bone formation, peristernal collections and infections, mediastinitis, retrosternal haematoma and edema. It is important to differentiate aortic dissection from rebleeding. Aortic dissection also causes mediastinal widening in post operative period. Clue is to look for displaced intimal calcification.

Thoracotomy and complications:-

Complications after lobectomy include atelectasis, pleural effusion, haemorrhage, air leak and infection. Potentially fatal complications include pulmonary embolism, cardiac herniation, lobar torsion, pneumonia, ARDS and respiratory failure.

Mortality is 2% and morbidity upto 40% after lobectomy. Normally there is ipsilateral mediastinal shift after pneumonectomy. With contralateral or no mediastinal shift consider bronchopleural fistula, haemorrhage, empyema in the post pneumonectomy. Mortality 6% and morbidity upto 60% after pneumonectomy.

Imaging findings:-

Post lobectomy normal findings: – Small amount of pleural fluid after drains are removed. Scattered lung opacities on the side of surgery. Effusion resolves during convalescence.

Post pneumonectomy normal findings: – 50 to 70 % of the hemithorax filled with fluid in 1 week. Complete filling with fluid in 2 to 4 months.

Normal mediastinal position: – Ipsilateral shift to the side of lobectomy. Returns to midline or close to midline as remaining lobes on the side of surgery hyper inflate. There is ipsilateral shift to side of pneumonectomy which is permanent.

Complications of lobectomy and pneumonectomy:-

Persistent pneumothorax, 10 to 20%.

Bronchopleural / bronchocutaneous fistula 2%.

Leak from suture line or bronchial stump: – Immediate post op period due to ischemia / infection.

Esophago-pleural fistula: – Most within 6 weeks of surgery due to adenitis, empyema or recurrent tumor.

Bronchial stump dehiscence: – Persistent pneumothorax, failure to fill with pleural fluid, drop in air fluid level of > 2 cm.

Hydrothorax: – Excessive pleural fluid. Consider poorly positioned chest tube, improperly positioned catheter with injection of fluid into pleura, thoracic duct injury and chylothorax.

Haemothorax: – Due to systemic, inter costal and mediastinal vessel laceration. Must be drained with chest tube or surgical ligation. Delay in treatment may result in fibrothorax and require decortication.

Empyema (< 5%):- Due to surgical contamination or from a bronchopleural fistula. Must be drained by chest tube. Delay results in fibrothorax, chronic empyema thoracic. Lung opacities seen in ICU patients are nonspecific from atelectasis and edema and is common in immediate post operative period.

Pneumonias: – Nosocomial, bronchopneumonia. Result of mechanical ventilation, narcotics, splinting, poor cough reflex and aspiration.

Elevated hemidiaphragm: – Consider phrenic nerve injury, atelectasis, pulmonary embolism or subphrenic abscess.

Cardiac herniation , pericardial defect :- Following intrapericardial pneumonectomy usually on right side, circulatory collapse, on right side there may be cardiac dextrorotation where cardiac apex lies against right chest wall “snow cone” appearance.

Left side – Cardiac levorotation

Post pneumonectomy syndrome (delayed complication)

After left pneumonectomy: Distal trachea and left main bronchus compressed between aorta and pulmonary artery.

After right pneumonectomy: Narrowed right upper lobe, bronchus intermedius and / or right middle lobe bronchi compressed between right pulmonary artery and spine

Torsion of a lobe or lung: After lobectomy. Remaining lobe rotates on its bronchovascular pedicle. 180-degree torsion leads to ischemia, infarction, and gangrene. Right upper lobectomy with torsion of right middle lobe is most common. Consider if abnormal position and orientation of pulmonary vessels are seen.

Herniation of lung through surgical defect in chest wall.: Accentuated by expiration.

References :

  1. Goodman LR et al: Congestive heart failure and adult respiratory distress syndrome. New insights using computed tomography. Radiol Clin North Am 34: 33-46, 1996.
  2. Ashbaugh DG et al : Acute respiratory distress in adults, Lancet 2 : 319-23, 1967
  3. Franquet T et al : Aspiration disease : Findings, Pitfalls, and differential diagnosis. Radiographics 20: 673-85, 2000
  4. Proto AV et al : Radiographic manifestations of lobar collapse. Semin Roentgenol 15: 117-73, 1980.
  5. Gluecker T et al : Clinical and radiologic features of pulmonary edema. Radiographic 19: 1507-31: 1999.
  6. Chest- top 100 diagnoses. Gurney JW, Wiener-Muram H,Amirys,2003,Reed Elsiever

Acute and non acute Schmorl’s nodes,disc vascularization : MR findings & recent concepts

 

Disc degeneration itself is a normal process in the elderly, beginning

as early in the twenties. There are 3 complications of degenerative disease of

the spinal column, making the normal process to a pathologic condition for

the individual : disc hemiation, spinal stenosis, and erosive osteochondritis.

MRI of erosive osteochondritis is characterized by disc vascularization and

bone marrow edema, both imaging features also found in infectious

spondylitis. Schmorl’s nodes can become vascularized like disc tissue in

erosive osteochondritis. There exist two types of Schmorl’s nodes: intraosseous

hemiation of nucleus pulposus tissue through the cartilaginous

endplate and hyaline cartilage proliferation originating in the trabecular bone

in erosive osteochondritis.

In disc degeneration, erosions of the adjacent vertebral endplates can be

present. However, the peripheral cortical bone of the vertebra is intact in disc

degeneration and frequently sclerosis can be found. Disc infections, on the

other hand, are frequently associated with destruction of the cortical borders

of the vertebra, the distinct dark rim of the endplate is then often focally not

visible on T1-weighted images. A gas density on CT is helpful to

distinguish degenerative disc vascularization in erosive osteochondritis from

spinal infection.

There is a high prevalence of degeneratively affected lumbar discs in MRI

examinations of people without back pain, and all degrees of disc

degeneration can be generally found in asymptomatic populations. However,

band-like vascularity in the disc space at the disco-vertebral junction is

associated with severe painful back syndromes . As bony changes and spurs at the endplates

are absent or only moderately developed segmental instability may play a causative role in

 the development of disc vascularity. Secondary disc vascularization represents a clinical condition

which can be diagnosed easily only by means of contrast enhanced MRI.

Therefore, MRI protocols in the work-up of patients with painful back

syndromes should include the application of paramagnetic contrast medium

and sagittal imaging planes after contrast medium injection, when previous

CT studies do not show disc herniation or other significant findings to explain

the patients symptoms. Degenerative disc vascularization is an important

differential diagnosis to bacterial spondylitis. It can be causative for pain in

patients with post-discectomy syndrome.

Gadopentetate dimeglumine enhanced MR imaging examinations of the

lumbar and thoracic spine is indicated for Schmorl’s nodes,

vascularization of Schmorl’s nodes, and associated bone marrow edema.

Sagittal T2-weighted SE and T1-weighted enhanced and non-enhanced SE

images with and without fat suppression  may be employed.

 

 

 

As the prevalence of Schmorl’s nodes decreases with age from youth to

adulthood, healing may be possible. Therefore, proliferative processes must

take place in the area of intraosseous herniation. At postmortem microscopic

examination, abnormal cartilage proliferation was noted in a 16 years old boy

with juvenile kyphosis in abnormal vertebrae and growth plates. In the

peripheral regions of the Schmorl’s nodes, where the vertebral bodies are in

contact with the node, growth of cartilaginous cells can occur. After

intraosseous herniation, ingrowth of vessels takes place from the adjacent

bone marrow into the periphery of the node and will progress to the center of

the node. It can be hypothesized that vascularization is requisite for cartilage

formation. Subsequent ossification contributes to sclerosis. By this

mechanism, sclerotic healing may be possible after ossification of the

cartilage.

 Only very few Schmorl’s nodes become symptomatic. Vascularity may be a

normal attempt to heal intraosseous cartilaginous hernias and is not

necessarily accompanied by back pain. However, enhancing Schmorl’s nodes

were bigger and more often accompanied by bone marrow edema in patients

with back pain than in those without. Enhancing Schmorl’s nodes should not

be confused with tumor or infection.

 

 

 

Suggested reading:

 

1.

Modic MT, Steinberg PM, Ross JS, Masaryk TJ, Carter JR
Degenerative disc disease: asessment of changes in vertebral bony
marrow with MR imaging.Radiology 1988; 166:193-199

 

2.Ross JS, Modic MT, Massaryk TJTears of the annulus fibrosus: assessment
with Gd-DTPA-enhanced MR imaging.AJR 1990; 154:159-162

 

3.Hamanishi C, Kawabata T, Yosii T, Tanaka SSchmorl’s nodes on
magnetic resonance imaging. Their incidence andclinical relevance.
Spine 1994; 19:450-453

 

4.Resnick D, Niwayama GIntravertebral disk herniations:
Cartilaginous (Schmorl’s) nodes.Radiology 1978; 126:57-65

 

5.Martel W, Seeger JF, Wicks JD, Washbum RLTraumatic lesions
of the discovertebral junction in the lumbar spine.Am J Roentgenol
1976; 127:457-464
6. Dr Axel Staebler, M.D. MR in D/D of disc space pathology :
Disc vascularization in acute degeneration ,
spondylitis,enhancing schmorls nodes :

Fwd: Paper Request

———- Forwarded message ———-
From: Atilla Çelik <dratillacelik@yahoo.com>
Date: Sun, Sep 21, 2008 at 3:43 PM
Subject: Paper Request
To: drhsdas@gmail.com
Dear Dr. Das.
I am Dr. Atilla Celik, from Istanbul, Turkey.
I am working at “Haydarpasa Numune Training & Research Hospital” as a General Surgeon.
I have seen your blog in recently. If it possible, I want to a copy of your published article that named “Large Adrenal Pseudocyst: Case Report with Review of Literature” in PDF format because of to cited our article “Laparoscopic management of giant adrenal cyst : Case report”.
Best wishes from Turkey.
Dr. Atilla Celik.
General Surgeon.
Haydarpasa Numune Training & Research Hospital
2nd Department of General Surgery
Istanbul, Turkey.
+90 216 5652728 (Home)
+90 532 4865625 (Cell)




LARGE ADRENAL PSEUDOCYST
CASE REPORT WITH REVIEW OF LITERATURE

Authors: H.S.Das, P.Hatimota, P.Hazarika, C.D.Choudhury,
*S. K. Barua, **S.J.Baruah
Institution: Matrix, G.S.Road, Guwahati-5 and Guwahati Medical College & Hospital
Key Words: Adrenal cyst MRI
Conflict of interest: None

INTRODUCTION:

Cystic pathologies of the adrenal gland are rare with an incidence of 0.06% in 1400 autopsies. The cyst most commonly found in the adrenal gland are Endothelial cyst (45%), Pseudocyst (40%), Epithelial cyst ((9%) and Parasitic cyst (7%). Pseudocysts are consequences of haemorrhage and degeneration and are usually nonfunctional.
Pseudocysts consist of a hyalinized fibrous capsule containing nest of adrenal cortical cells and amorphous cystic contents composed of admixture of serum, blood and fibrin. Adrenal pseudo cyst vary greatly in size from microscopic to more than 50 cm with highest incidence in 5th and 6th decade with female preponderance.
Symptoms are usually associated with large cyst due to compression of surrounding viceras, pain & vague GI complaints. Imaging studies by CT scan & preferably by MRI Scan helps it to differentiate it from other adrenal pathologies. Surgical extirpation is indicated in presence of symptoms, endocrine abnormalities, complication, large size or suspicion of malignancy.
We report a case of symptomatic pseudo cyst of adrenal gland in an adult female without any hormonal abnormalities which was excised through thoraco-abdominal approach. Surgery was uneventful and patient is asymptomatic at 18 months of follow up.

CASE REPORT:

A 35 years old female presented with a one year history of non specific abdominal discomfort & occasional pain in left upper abdomen. Routine laboratory tests were within normal range. USG showed a well defined approx. 10 cm cystic mass in relation to upper pole of left kidney. MRI showed a large cystic mass separated from upper pole of the kidney with a low signal intensity in T1 weighted images and high signal intensity in T2 weighted images. A complete endocrine workup failed to detect any hormonal hypersecretion. A prospective diagnosis of left adrenal cyst was made and the lesion was excised through thoraco-abdominal approach via 11th rib.
The cyst measured approx. 10 cm in its largest dimension which on cutting open revealed chocolate colored fluid. The wall thickness varied from 0.1 to 0.2 cm. and pathological section revealed fibrous wall without any epithelial lining. The patient had an uneventful post operative recovery. She is completely symptom free at 18 months of follow up visits.

DISCUSSION:

Cysts of the adrenal gland are uncommon lesions and represent 80% of cystic adrenal masses. The etiology of pseudocyst is not well understood but is believed to arise from organization of prior haemorrhage or infectious process (1). Pseudocyst account for 40% of all cystic lesion of the adrenal gland and are consequences of haemorrhage and degeneration (2).
Most adrenal cyst are asymptomatic and less then 10 cm in diameter when discovered incidentally (3) or at autopsy (4). Symptoms appear when pseudo cyst enlarges sufficiently to cause pain and GI disturbances or become palpable (3) as in our patient. Large cyst has tendency to develop complications such as intractable haemorrhage and rupture which can manifest as a surgical emergency (5).

The haemorrhage within these lesions often give atypical imaging features on CT. Ultrasonography which could be confused with an adrenal tumor (6) . MRI is useful in differential diagnosis of adrenal cyst (7) and can differentiate it from pheochromocytoma (8).
MRI shows homogenously low intensity on T1 weighted images and high intensity on T2 weighted images in case of adrenal pseudo cyst (9, 10).
Pseudocyst may be isolated or associated with primary adrenal neoplasm such as Pheochromocytoma, adrenal adenoma, adrenocortical carcinoma and neuroblastoma (11). Pseudocyst could be confused with adrenal tumors both clinically and radiographically (12) . The more complex pseudocyst should be distinguished from cystic degeneration in adrenal malignancy and from cystic renal cell carcinoma in upper pole (2) .

Surgical excision is indicated in presence of symptoms (13), endocrine abnormality (even when subclinical), complications, large size (>5 cm) or suspicion of malignancy (14). Laparoscopic drainage (15, 16) or open surgical extirpation with preservation of adrenal tissue remains the treatment of choice. Large size, increased wall thickness or calcification are features of malignant changes which should be excised and followed up for cystic recurrence, late metastasis or adrenal endocrine dysfunction.
Other lesions that should be considered in the differential diagnosis of cystic adrenal masses are endothelial cyst, lymphangioma, epithelial cyst and parasitic (hydatid) cysts (17, 18).

REFERENCES:

1. M.A.Habra , Barry W Feig , Steven G Waguespack. , Adrenal Pseudocyst
The Journal of Clinical Endocrinology and Metabolism, 2005; 90(5) : 3067-68

2. Guensens E , De Man R, Van Oost J, Vuylsteke P., Large Adrenal Pseudocyst
, J . Belge. Radiol. 1993 ; 76(5): 322-3

3. Tagge D U , Baron P L , Giant adrenal cyst : Management and review of literature
Am. Surg. 1997; 63(8) : 744-6

4. Luciano AFavorito, Felipe M. Lott, Andre G Cavalcante. Tarumatic

rupture of adrenal pseudocyst leading to massive haemorrhage in

retroperitoneum , Int. Braz. J Urol. 2004; 30 (1), Abstract from SciELo Brazil

5. Chew S P, Sim R , Teoh TA , Low CH. , Haemorrhage in to non functional adrenal

cyst- report of two cases and review of literature. Ann. Acad. Med. Singapore

1999;28: 863-6

6. Sakamoto I , Nakahara N. , Fukuda T. et. al . , Atypical appearance of Adrenal

Pseudocyst. J Urol, 1994;154(1): 150-2

7. Ito N., Fujimoto H, Arai Y, Nishimura K et. al. Two cases of adrenal cyst- the

meaning of imaging in diagnosing adrenal cyst. Hinyokika Kiyo, 1989;35(7): 1161-6

8. Hidetaka Suga et. al. , 14C, Jan 2003; 42(1) Crossed ref. Medline

9. Yashushi Tanuma , Makoto Kimura , Shigeru Sakai. Adrenal Cyst- A review of the

Japanese Literature and report of a case. International Journal of Urology, 2001;

8: 500

10. Chihangir Erem , Fatih Celik , Abdulkadir Reis et. al. Large adrenal pseudocyst

presenting with epigastric distress and abdominal distension ,
Medical Principle & Practice, 2005; 14: 284-87

11. Erickson L.A., Lloyd RV , Hrtman R , Thompson G. , Cystic Adrenal Neoplasm,
Cancer, 2004; 101: 1537-44

12. deBree E., Schoretsanitis G , Melissas J et. al. , Cyst of Adrenal Gland: Diagnosis and

management , Int. Urol. Nephrol., 1998; 30(4): 369-76

13. N. Sezhian, D. Rimal , G Suresh . Adrenal Pseudocyst- Diagnostic Dilema
,Scottish Medical Journal, 2005; 45(2): 81

14. Manuel Suarez, Sheldon Bastacky, Vascular adrenal cyst . Final Diag. Case- 182,

2005, Crossed ref. Medline

15. Koksoy Ferda N , Yucel Osman , Celik Atilla et. al. Laparoscopic management of giant

adrenal cyst : Case report , Surg. Lap. End. PCN Technique, 2001;11(6); 379-81

16. Prashad R., Kumar M., Pseudocyst of adrenal gland,
Med. J, Malayasia, 2002; 57(1): 125-7

17. Satou T.,Uesugi T , Nakai Y et. al. , Case of adrenal lymphangioma with atypical

lymphocytes in aspirate cytology. Diag. Cytopathol., 2003; 29: 87-90

18. Ackay MN , Akcay G, Balik AA , Boyuk A , Hydatid cyst of the adrenal gland : review

of nine patients. World J Surg, 2004;28: 97-99

Figures :
1- MRI , 2- Specimen , 3- Histopathology

* Registrar Deptt of Urology, GMCH
** Prof Deptt of Urology, GMCH

Address for Correspondence:
Dr Himadri Sikhor Das,
Matrix,1st Byelane Tarun Nagar
Near Rajiv Bhawan, G.S.Road,
Guwahati-5
Tel:+0361-2595078
Email: drhsdas@gmail.com

ROLE OF IMAGING IN PAEDIATRIC EPILEPSIES

Role of Imaging in pediatric epilepsy

Summary: An epileptic seizure is a clinical manifestation of abnormal, excessive neuronal activity arising in the gray matter of the cerebral cortex. Epilepsy in the pediatric population is fairly a common problem in day today practice. Recent advances in the imaging sciences has revolutionized the diagnosis and management of all types of epilepsies, especially with the advent of epilepsy surgery, detailed imaging has become mandatory. Yet the crucial aspect of assessment is not the radiological, but the clinical history and examination. Imaging is not required in all cases of childhood epilepsy, a proper clinical history is thus essential to identify the epileptic seizure. This group includes idiopathic generalized epilepsy (benign myoclonic epilepsy of infancy, childhood absence epilepsy, juvenile absence epilepsy juvenile myoclonic epilepsy) or benign epilepsy of childhood with Centro temporal spike where imaging is usually not necessary. CT and MRI are routinely used for imaging purpose ,though in an ideal situation MR should be the choice of imaging modality except in those cases calcification is to be ruled out, CT plays a major role. Out of common causes of epilepsy where imaging is necessary include hypoxic ischaemic encephalopathy, congenital abnormalities, mesial temporal sclerosis, infections, tumors and vascular malformation.

Diagnosis of epilepsy involves four stages.

· Recognition of epileptic seizure
· Classification of seizure types
· Identification of epilepsy syndrome
· Identification of the underlying etiology

These can be achieved by clinical including family history, examination findings, EEG including video imaging, blood tests, metabolic screening and lastly neuroimaging.

Indications for imaging

MRI is particularly indicated in patients with one or more of the following (Ideal practice)
International league against epilepsy.

· Onset of seizures at any age with evidence of a partial onset on clinical or EEG findings
· Onset of unclassified seizures or apparently generalized seizures in first year of life or in adulthood.
· Evidence of focal fixed deficit in clinical or EEG findings
· Failure to control the fits with first line of drugs
· Failure to control fits or change in the seizure pattern.

Neuroimaging is not done with a definite EEG evidence of idiopathic generalized epilepsy like benign myoclonic epilepsy of infancy, childhood absence epilepsy, Juvenile absence epilepsy ,JME and benign epilepsy of childhood with Centro temporal spikes.

Aim of neuroimaging
· To identify underlying pathology
· To aid the formulation of syndromic and etiological diagnosis.

Imaging modalities.
· MRI
· CT scanning
· Nuclear medicine SPECT and PET
· DSA
· Plain X-ray

MRI:
· Routine study,
· Dedicated seizure sequences,
· Functional MRI (fMRI)
· Spectroscopy

Routine MR study
Conventional sequences aims to find out any overt structural lesion in the brain. Axial, coronal and sagittal sequences with T1 and T2 weighted images are obtained. Additional FLAIR sequence is helpful to detect minor signal alteration.

Dedicated seizure protocol

This is necessary when no gross pathology is found in the routine sequences. This is done specially in the temporal lobe epilepsy to demonstrate any lesion in the structures of the medial temporal lobe.

· Heavily T2 weighted sequence in coronal plane
· T1 inversion recovery sequence in oblique coronal (the
right angles to the hippocampus).
· Hippocampal volumetric study to study the size and asymmetry
· T2 relaxometry ( T2 mapping) for Hippocampus and amygdala
· Spectroscopy

Functional MR

This is necessary when question of epilepsy surgery is considered. The technique used is called BOLD.(Blood Oxygen Level Dependant ).Patient is asked to perform some activity. The activated areas of the cerebral cortex will have increased blood flow without increase in the oxygen consumption suggesting anaerobic metabolism. This leads to increase in the oxyhaemoglobin level in the activated area. Deoxyhaemoglobin is paramagnetic and affects the T2 signal. The signal intensity in the activated area becomes different from the rest of the brain where the deoxyhaemoglobin predominates. In the activated area the T2 signal is preserved. This is the basis of BOLD. This difference in signal can be depicted in map. Increased BOLD signal can be obtained in the seizure focus in the interictal states in sites of EEG discharge. The main application of this in seizure is localization of motor strip.

Spectroscopy

By MR spectroscopy brain metabolites are analysed. Usually proton magnetic spectroscopy is performed. N-acetyl aspartate, choline and creatine. With neuronal loss the NAA level is reduced and in gliosis and astrocytosis the Creatine and Choline are increased. These can be analysed quantitavely or in graphical manner.

CT scanning
CT can be used as an initial screening procedure for overt tumours, infection etc, however MRI is preferred due to lack of radiation, increased spatial resolution and multiplanar capability. CT is specifically indicated to find out calcific foci.

Nuclear medicine: SPECT- ictal, post ictal and interictal SPECT
PET- glucose metabolism

Plain radiography- Limited role.

Imaging can be discussed according specific seizures

· Temporal lobe epilepsy
· Other Focal seizures
.

Temporal lobe epilepsy

This is complex partial seizure where the focus is generally in the temporal lobes. Causes can be divided into following category.

Mesial temporal sclerosis – Hippocampal sclerosis
- Hippocampal sclerosis and other temporal lobe abnormality
- Hippocampal sclerosis and extratemporal abnormalities
- Amygdalar sclerosis

Structural lesions Tumours
Infective lesions
Vascular malformation
Congenital and developmental lesions

Mesial temporal sclerosis

In this condition there is gliosis and neuronal loss involving the structures of mesial temporal lobe. Mesial temporal structures include hippocampus, parahippocampal gyrus, amygdala, entohinal cortex and subiculum.

Hippocampal sclerosis

This is condition in which there is focal sclerosis in the hippocampus. It is the most common cause of intractable epilepsy. Hippocampal sclerosis is important in epilepsy because
· It is the commonest lesion found in intractable epilepsy
· It is epileptogenic
· Identification of epileptic surgery

MR findings:

· Altered signal in the hippocampus
· Ipsilateral temporal horn dilatation
· Reduced hippocampal volume
· T2 relaxometry-increased signal
· Loss of grey white demarcation

Dual pathology:

Hippocampal sclerosis and extratemporal structural abnormality.

Other Focal seizures:

In most of the cases CT and routine MR sequences are enough to give an etiological diagnosis. The common causes of paediatric importance can be broadly classified as followed-:

· Congenital and developmental abnormality.
· Hypoxic ischaemic lesions
· White matter diseases
· Infections and infestation

Congenital and developmental abnormalities

Neuronal migration disorders:

This is one of the common conditions causing seizures in the paediatric population and most of the time this is under diagnosed. This is a condition were there is incomplete or abnormal migration of neurons from the germinal matrix to the cerebral cortex. During 7th weeks of gestation proliferation of neurons occur in the subependymal layer in the wall of lateral ventricles. This is area is called germinal matrix. From this region neurons start migrating to its final destination from 8th weeks of gestation and continues upto 20th week of gestation.

Lissencephaly:

Lissencephaly means smooth brain. There is paucity of sulcal development. If there is arrest of migration then it produces classical lissencephaly and when there is over migration the it produces cobblestone lissencephaly.
Classical lissencephaly the patient present with DDM and seizure. There is hypotonia at birth and spasticity at later life. There may be infantile spasm and medically refractory epilepsy at early age. Systemic abnormalities in heart, ear, eyes and kidneys may be present. On imaging there is smooth brain, shallow vertically oriented sylvian fissures giving rise to figure of 8 appearance. There is a zone of white matter separating the thin superficial cortical gray matter from thick layer of gray matter. There is reduced white matter density.

Heterotopia.

Collection of nerve cells in abnormal location due to arrest of migration. Patients invariably presents with seizure. Some of them presents with medically refractory epilepsy. Three types of heterotopia.

Subependymal
Focal sub-cortical.
Band heterotopia.

In subependymal heterotopia presents with normal development, normal motor function and seizure disorder. In focal subcortical Type there is medically refractory seizure and delayed motor development. In band heterotopia there is delayed developmental mile stones and seizure.

Schizencephaly

These are gray matter lined clefts extending from the pial surface to the subependymal layer. These may be closed lip when the lips are closed and open lip when the lips are open. This may be unilateral or bilateral, symmetrical or asymmetrical. Symptoms are more sever in the bilateral type. Varible motor dysfunction and seizures are common features.

Polymicrogyria.

Abnormal too many gyri separated by shallow sulci. Histologically there is laminar cortical necrosis in the cortical layer V .The cortical layer II, III, IV are normal. 90% patients present with seizures.

Focal cortical dysplasia

Focal abnormality in the cerebral cortex which may be trivial to be diagnosed in the MR scans. In mild cases there is mild blurring in the grey white junction. In others there may be flat smooth gyri( pachygyria) . Histologically they are not associated with abnormal balloon cells extending from cortex to the lateral ventricular wall.

Focal transmantle cortical dysplasia.

Here there is abnormal cells extending from the walls of the ventricles to the cortex. Histologically abnormal cells are seen in the cortex and in the underlying white matter. Abnormal cells include large atypical neurons, atypical glial cells, and balloon cells mixed with normal neurons. On imaging the involved portion is large, abnormal cortical pattern, broad gyri, irregular sulci.There is change in the signal intensity also .A Hyperintense linear line is seen extending from the abnormal cortex to the lateral ventricular wall. The gray white matter junction is blurred.

Neuro-cutaneous syndrome :

Four types of these, out of which the tuberous sclerosis usually presents with Seizure.

Tuberous sclerosis

These patients presents with classical triad.- seizure, adenoma sebaceum and delayed developmental milestones. The pathogenesis of this entity is uncertain, however this it thought to be due to disordered migration of dysgenetic neurons. There are four types of CNS lesions may be present.

· Cortical Tubers
· White matter abnormality
· Subependymal nodules
· Subependymal giant cell Astrocytoma.

Hypoxic ischaemic lesions

Localized infarction: -

These patients have variable presentation. Neonates typically present with seizures, hypotonia and lethargy whereas infants present with hand preference. In older children representation is like adults.
All most in 50 % of local brain infarction the cause is not known. In patients where cause is identified commonly related to cyanotic heart disease, sickle cell disease and moya moya disease. There are other metabolic causes of stroke in children. Imaging appearance are similar to that of older children and adult.

Diffuse ischaemic brain insult: –

Antenatal, postnatal and perinatal vascular events ,either hypoxic , ischaemic or hemorrhagic
May lead to wide range of abnormalities . Most of these insults will produce seizures at a later life .

Three factors are responsible for different pattern of brain injury.

Severity of hypotension.
Maturity of brain at the time of insult.
Duration of insult.

Severity of hypotension :-

In mild to moderate hypotension blood flow is shunted from anterior to posterior circulation. To maintain perfusion in brainstem, cerebellum and basal ganglia. Watershed zones of cerebral hemispheres are effected. In profound hypotension shunting is not possible so deeper structures like thalamus, basal ganglia and brain stem are affected.

Maturity of brain at the time of insult :-

Knowledge of blood circulation to the brain is necessary to understand the hypoxic damage to the neonatal brain. There are two sets of vessels. One cortical vessels the penetrate and they anastomose with the ventricular vessels in the periventricular region. In premature brain the cortical branches anastomose with the ventricular vessels in immediate periventricular region whereas in mature infant the anastomosing zone shifted to the peripherally. If ischaemic injury occurs in premature infant the infarctions are located in the immediate periventricular regions. But in mature infant or older children the infarctions are watershed zone and the subcortical periventricular white matter. The periventricular region contains the corticospinal tracts. These tracts are arranged in such a way that the immediate periventricular region contains fibres for the legs so bilateral involvement produces spastic diplegia at a later date. Again the geniculocalcarine fibres also travel in the peritrigonal region so most of these child suffers from visual abnormality.

CNS infections

· Both meningitis and encephalitis can produce seizures.
· Parenchymal infections like tuberculomas and cysticercosis frequently produces seizures. Cerebral abscesses rarely produce seizures.
· Congenital infections -

D/D of ring lesion.

Causes:

· Cysticercosis
· Tuberculoma
· Micro abscess
· Vascular lesion
· Demyelinating lesions

Cysticercosis Vs Tuberculoma
· Size
· Eccentric nodule
· Calcification
· Muliplicity

MRI in ring lesions

MRI is superior to CT scan in differentiating the different ring lesions. It is much more efficient diagnosing cysticercus cyst. A classical granuloma is identified by T2 hypointense Signal. A vascular lesion like aneurysm and AVM is seen as flow void if it associated with high flow.

Congenital infections:

Congenital infections include Cytomegalovirus, Toxoplasmosis, Rubella, Herpes simplex, HIV and Syphilis etc.

Cytomegalovirus infection: There are parenchymal calcifications predilection for the periventricular region. There is ventriculomegaly, atrophic changes, delayed Myelination and neuronal migration disorder.

Toxoplasmosis:

There are parenchymal calcifications not specific for periventricular region hydrocephalus and atrophy. No migrational disorder is noted.

Vascular malformation:

Four types vascular malformation is seen

· Arteriovenous malformation
· Cavernous angioma
· Capillary telangectasis
· Venous angioma.

Intracranial tumors

Though most of the tumors present with raised ICP some of the tumors grow very slowly like temporal lobe glioma, DNET, gangliglioma and oligodendroglioma etc.

MOYA-MOYA SYNDROME

MOYA – MOYA SYNDROME

Moyamoya is a Japanese term which translates in english to: “cloudof smoke” or “puff of cigarette smoking drifting in the air” and it has been used to define a classic angiographic appearance of multiple small intracranial vessels . Although described first in Japan in the 1950s this form of cerebrovascular disease is not limited to the Japanese population and has been reported sporadically all over the world with cases described in the United States, Europe, Australia and Africa. The incidence seems to be roughly one in a million people per year. There seem to be two definite peaks of incidence: children under 10 years old and adults in their third to fifth decades of life. A slight female preponderance has been shown. There is some evidence of familial tendency based on association between moyamoya and certain HLA types. Familial incidence is estimated about 7 to 12% around the world.
The Moya moya pattern of vessels seen on angiography is thought to be a phenomena secondary to intracranial large vessel narrowing or stenosis. The response of the cerebral vasculature to this type of narrowing is for more distal vessels to proliferate. There is debate as to whether the vascular abnormality represents a congenital problem or an acquired stenosis of intracranial vessels that occurs early in life. Moyamoya type changes have been found in a variety of diseases, including sickle-cell disease, neurofibromatosis, trisomy 21 and fibromuscular dysplasia. Other predisposing conditions for this problem include an auto immune process, cranial trauma, anaerobic bacteria or the use of oral contraceptive but none has been convincing. There are no specific symptoms or signs related to moyamoya syndrome. The various clinical manifestations are generally caused by cerebrovascular ischemic or hemorrhagic events. Headaches and seizures are also seen. Clinically the disorder presents in children with transient ischemic attacks (TIA) frequently with episodes of hemiparesis or other focal neurological signs, often precipitated by physical exercise or hyperventilation. There may be a more chronic course of worsening with a gradual impairement of intellectual deterioration. Adults in contrast, usually present with intracerebral hemorrhage, most frequently in the thalamus, basal ganglia or deep white matter. Subarachnoid or intraventricular hemorrhage may also be observed. Other signs and symptoms seen in children and adults are disturbance of consciousness, speech disturbance, sensory impairment, involuntary movement and visual disturbance. The prognosis of moyamoya is difficult to predict because the natural history of the disease is still unclear. Autopsy studies have shown severe vascular occlusive changes in the intracranial portion of the ICA usually bilateral and in the main arteries that make up the circle of Willis. These changes are characterized by endothelial hyperplasia and fibrosis with intimal thickening and abnormalities of the internal elastic lamina, while the adventitia and media remain normal. Descriptions of the vertebrobasilar system are not available. Extracranial arteries at the level of heart, kidney and other organs may show the same intimal lesions as the intracranial arteries supporting the belief the moyamoya syndrome can be a more generalized systemic vascular syndrome. Inflammatory cells or atheroma are not typically seen. The intracerebral perforating arteries around the circle of Willis show micro aneurysm formation with fibrin deposition and thinning of the vessel wall. These types of changes are thought to be responsible for the occurrence of intracerebral hemorrhage. It is postulated that there is increased blood flow through these small fragile vessels making them prone to hemorrhage.Cerebral angiography is the cornerstone of the diagnosis of moyamoya syndrome. The characteristic angiographic findings of moyamoya syndrome are a symmetrical stenosis (tapering) or occlusion of the intracranial internal carotid artery, as well as the origin of the anterior and middle cerebral artery associated with an enlargement of the basal penetrating branches of these arteries in an apparent attempt to provide collateral circulation and giving the classic “cloud of smoke” appearance . Computed tomography scaning shows non specific findings. There may be ischemic areas of the cortex and sub cortical white matter with evidence of old areas of infarction. There may be mild ventricular dilatation or dilated sulci and fissures. In the case of intracerebral hemorrhage the CT scan will show the location of the intraventricular, subarachnoid nd intraparenchymal hemorrhage that usually occurs in the basal ganglia or thalamus .Magnetic resonance imaging may better visualize areas of cerebral infarction due to moyamoya. Usually these infarctions are multiple, small and asymptomatic.
Infarction is seen predominantly in the watershed areas of the carotid circulation at the borderzone between the areas of the brain supplied by the middle cerebral artery and anterior cerebral artery.Magnetic resonance angiography (MRA) can be used to detect the abnormal intracranial vessels although its resolution does not yet allow the visualization of the abnormal basal penetrating vessels. Other techniques including positron emission computed tomography(PET), single photon emission computed tomography (SPECT) and perfusion MRI studies have been used to study regional cerebral blood flow in moyamoya patients. There are still not enough available data to draw any conclusion about the usefulness of these techniques in the diagnosis of this condition. Transcranial Doppler has recently been used to study patients with moyamoya syndrome and has been shown to be a very useful non invasive technique to follow changes in larger vessels with time. The best treatment is not known. The treatment of moya moya patietns depends on the pattern of symptoms. For patients with ischemic events and infarction, medical therapy consists of management with steroids in certain instances. Aspirin, ticlopidine and occasionally vasodilators and anticoagulants may be used. No study has supported the definitive efficacy of any medical treatment. A variety of different surgical revascularisation procedures have been used, but whether they improve the outcome is not yet known. Superficial temporal artery-middle cerebral artery bypass, encephalodurosynangiosis,omentum transplantation and cervical sympathectomy are options. The main purpose of surgical procedures is to provide additional collateral flow to an are of ischemic brain and therefore to prevent further damage. Encephalodurosynangiosis (EDAS) is performed with the intent to divert flow from the external carotid artery into the internal carotid artery system by applying branches of the superficial temporal artery or the temporal muscle to the brain surface of a patient. Finally omentum transplantation is performed with the intent to revascularize ischemic tissue. Cervical sympathectomy including stellate ganglionectomy is performed with the intent of improving cerebral blood flow. For treatment of hemorrhage, hematoma evacuation and ventricular drainage are the usual methods of treatment. There is no specific medical or surgical therapy proven to reduce subsequent hemorrhage. Some patients with moyamoya stabilize clinically, often after they have developed disabilities, others continue to show progressive deterioration despite treatment.Although no definite effective treatment has been determined, surgical therapy to augment collateral circulation appears to be a promising treatment for patients with relapsing ischemic events.

IMPROVING RADIOLOGICAL SERVICES IN INDIA ALONG THE LINES, OBSERVATIONS AND SUGGESTIONS PROPOSED BY EUROPEAN RADIOLOGICAL ASSOCIATION STANDARDS 2003:

IMPROVING RADIOLOGICAL SERVICES IN INDIA ALONG THE LINES, OBSERVATIONS AND SUGGESTIONS PROPOSED BY EUROPEAN RADIOLOGICAL ASSOCIATION STANDARDS 2003:

Dr Himadri S. Das
Guwahati, Assam

At the introductory meeting held at IAEA headquarters in Vienna in March 2003 on Thematic Planning for Diagnostic Radiology, representatives of the IAEA indicated that the Agency wished to take a more holistic approach to the improvement of global radiological services by helping to develop adequate standards for the 135 Member States, and by developing partnerships with other organizations with similar interests. Within IAEA there are already four programs in the health area covered by the Division of Human Health namely Nuclear Medicine, Radio Biology, Dosimetry/Physics & Nutrition. The focus is on identifying a role for nuclear sciences and technology in addressing human health problems particularly in developing countries, rather than duplication of activities already covered by other agencies, i.e. a complementary and co-coordinating role with a focus on patient radiological services, rather than strictly regulatory aspects. Specific concerns expressed during the meeting included the absence of access to Radiology services for two thirds of the world’s population, and the predicted growth in malignant disease in both developed and developing countries over the next decade requiring significant Investment in trained staff and equipment.

Access to health care should be a basic human right. Diagnostic Radiology is fundamental to the proper assessment and monitoring of many diseases processes, and is required in around 25% of medical Interventions. The challenge is to maximise the utilisation of diagnostic equipment in a timely fashion to expedite diagnosis and initiate appropriate treatment. Emergency Radiology services are now required on a 24 hour / 7 day week basis. Screening for early diagnosis of disease e.g. breast and lung cancer and vascular disease, provides an organizational, financial and ethical challenge. Research into the next developments in imaging is required. Many of these stem from the genomics project, and the requirement for molecular imaging and cellular imaging, in order to promptly identify disease processes and follow response to therapy.

It is appropriate that the worst cases are prioritized, i.e. third world and highly populated countries like India, or those affected by recent conflicts, are supported in the provision of, at least, basic radiology services. The development of pilot centres of excellence as already in effect in the WHO initiative would be a good starting point. These could be hospital and/or community based and should offer the possibility of providing a “critical mass” of trained Radiologists and Radiographers and support staff drawn from the indigenous population, with practical support and encouragement from outside gencies and national governments.

These could provide the framework for the development of training programmes and benchmarks for staff development, and are more likely to have basic infrastructure, e.g. a reliable electrical supply, required to underpin an ongoing radiological service, and the pump priming of sustained academic development.

Basic X-ray equipment, which is robust and easy to maintain, should be provided. Image processing using film based systems may require a lower initial investment, but Computed Radiography (CR) systems offer lower revenue expenditure in the long term and the possibility of image transmission (tele-radiology) or reporting/second opinion, if the local telecommunications system is capable of supporting this technology. Basic Ultrasound equipment has become cheaper and more sophisticated and small portable units have now got quite sophisticated capability including colour Doppler imaging. These are invaluable in obstetric assessment, as well as general abdominal and small parts: thyroid, testis, breast, etc. evaluation, and also for vascular evaluation and paediatric cerebral examination. With good tuition, those with basic anatomy and pathology training can master the operational skills without too much difficulty. Training programmes could be provided on a “fellowship” basis. The capital cost of CT scanners has relatively declined in recent years. Regular planned maintenance is essential. Modern X-Ray tubes are relatively resilient. A properly planned CT examination is a flexible and powerful diagnostic tool and should be available in any “core” hospital department. Targeted contrast agents and the development of new MRI sequences leading to functional imaging are of particular importance, especially in Neuro-Radiology. Collaborative multi centre studies are required and could be supported.

Radiology services require teamwork and the involvement of trained Radiographers, Clerical/Administrative staff and Medical Physicists. Nowadays IT Staff are essential to support Radiology Information Systems (RIS), Picture Archiving and Communications Systems (PACS) and integration with Hospital Information Systems (HIS). These arrangements support the provision of comprehensive Radiology services and are usually based in hospitals or clinics.

Lack of comprehensive training leads to emphasis on one modality, sometimes undertaken by physicians with no formal Radiological training. Similarly, absence of reliable up-to-date equipment also limits the quality and range of diagnostic & therapeutic options. In the worst scenario, as indicated above, there is a complete absence of Radiological services, often compounded by other fundamental problems: starvation, lack of clean water, electricity and telecommunications, and the presence of endemic diseases – AIDS, malaria, hepatitis, Tuberculosis etc.

In Europe, postgraduate training in Radiology lasts for five years, following medical qualification and experience. Modalities used are: X-ray Fluoroscopy, Ultrasound, Computed Tomography (CT) and Magnetic Resonance Imaging (MRI). Recently, Positron Emission Tomography (PET) has been added to the diagnostic armamentarium – often in conjunction with CT (e.g. CTPET).

The situation in India is after basic medical qualification (MBBS degree) and general medical experience, postgraduate training in Radiology (MD) lasts for three years. Diploma courses (DMRD) are offered in few places. Some Radiologists sub-specialise, usually on the basis of Interest in one or other organ systems, but most Radiologists conduct a Radiological practice utilizing Radiographic Images derived from X ray, USG & doppler with CT, MRI etc being available in few Governmental Hospitals, nursing homes, general purpose diagnostic centres and the likes. New entrants are corporate hospitals with ultramodern equipments but these lack the experience of properly trained Radiologists WITH the experience of using such machines.

The Government, Radiological Associations and regulatory bodies could help to:

1. Co-operate in the provision of training and educational standards

2. Inspect and advise on training centres

3. Encourage the development of national legislative requirements in Radiation protection. Provide quality and benchmarking guidelines for Radiology Department management.

4. Upgrading Guidelines on Pregraduate and Postgraduate training in Radiology and in Continuing Medical Education. Referral Guidelines for physicians setting out an appropriate radio diagnostic approaches.

5. Encourage Radiologists to provide leadership in the provision of high standards in radiological services.

Significant funding is required if we are to compete with our international colleagues who have been successful in attracting huge government funding to new national radiological research institutes. The world of Diagnostic Radiology is a referral specialty of medicine providing services in medical imaging and image guided Interventional techniques to the patients of Medicine and allied practitioners, surgeons, oncologists and other medical specialists.

NEURORADIOLOGY DIFFERENTIAL DIAGNOSES

Neuroradiology Differential Diagnoses
(Original Text from Spencer Gay, MD, UVA)

POSTERIOR FOSSA MASS – CHILD
Cerebellum/IVth Ventricle
- Medulloblastoma – midline, vermian or roof – usually hyperdense on plain CT -
often enhance homogeneously – Astrocytoma
- usually PILOCYTIC ASTROCYTOMA – 2/3 are cystic with mural nodule – cyst fluid
denser than CSF due to protein
- Ependymoma – INTRA-ventricular – “cast” of lumen – 50% are calcified
Brainstem – Brainstem glioma – expands brainstem (infiltration w/o destruction)
- hydrocephalus (may be late)
Extraaxial fluid collection
- Large cisterna magna (“Mega Cisterna Magna”)
- Epidermoid inclusion cyst
- Arachnoid cyst (may bevel inner table of skull) – Dandy Walker cyst of 4th
ventricle (look for vermian abnormalities)
- Vermian agenesis
- Chronic subdural hematoma
COMMENT: For a posterior fossa mass one should consider the direction of
displacement of the 4th ventricle to assess from which compartment it arises

POSTERIOR FOSSA MASS – ADULT
Extraaxial:
- Vestibular Schwannoma (CPA)
- Meningioma
- Ependymoma
Intraaxial:
Metastasis – most common intraaxial neoplastic post fossa mass in adult
Hemangioblastoma – cystic or solid – angio shows hypervascularity & stain
Astrocytoma – usually not vascular on angio
Medulloblastoma – often more lateral in adults Lymphoma Abscess Infarct

CEREBELLAR ATROPHY
Drugs
- Alcohol (vermis)
- Dilantin (hemispheres)
- Chemotherapeutic agents
Vascular process (incl. infarction)
Trauma
Hyperthyroidism
Paraneoplastic – lung, breast, lymphoma, ovary
Olivopontocerebellar degeneration
COMMENT: Cerebellar sulci > 1 mm, enlarged 4th ventricle, enlarged cisterns

MASS IN CLIVUS

Chordoma – bone destruction
Meningioma – hyperostosis
Local invasion
- nasopharyngeal cancer
- pituitary tumor
Metastasis
Chondrosarcoma (more often paramedian)
COMMENT: A basilar artery aneurysm may appear to arise from the clivus – look
for pulsationartifact in the phase encoding direction

BRAINSTEM LESION
Brainstem glioma
- present with cranial nerve palsies
- hydrocephalus less common
Infarction
Hemorrhage – often hypertensive
Pontine myelinolysis (“central”, aka. “Osmotic Myelinolysis”)
Multiple sclerosis
Metastasis
Basilar artery aneursym/dolichoectasia may displace brainstem


CEREBELLOPONTINE ANGLE TUMOR

Vestibular Schwannoma (aka. “Acoustic neuroma”)
- enlarges IAC, rounded mass in cistern
- enhances with IV contrast and Gadolinium DTPA
- large (>2.5 cm) schwannomas heterogeneous
- bilateral lesions in NF-2
Meningioma
- does not enlarge IAC
- enhances homogeneously
Epidermoid
- hypodense
- enlarges cistern
- serpentine margin
- FLAIR sequence may distinguish from CSF (arachnoid cyst)
Exophytic brainstem glioma
- progressive cranial nerve palsies
Acquired Epidermoid (“Cholesteatoma”)
-erupts from middle ear
- signs of mastoiditis, Hx of ear infection
Metastasis
Basilar artery aneurysm
Glomus jugulare
Trigeminal schwannoma (may “dumbell” into middle fossa)
Arachnoid cyst (homogeneous CSF density and signal)

CT PROGRESSION OF INTRACRANIAL HEMATOMA
(change from HYPER- to HYPO- dense over time)
Initially – 60 – 90 Hounsfield Units (HU)
2 days – 70 HU
3 weeks – 30 HU
>5 weeks –
MRI APPEARANCE OF INTRAPARENCHYMAL HEMATOMA
(T1/T2: II, ID, BD, BB, DD (I-iso, D-dark, B-bright)
Hyperacute – minutes to hours (DD => II)
- T1WI – hematoma hypointense (deoxyHb) => isointense
- T2WI – hematoma hypointense (deoxyHb) => isointense
Acute – 0-2 days (ID => BD)
- deoxyhemoglobin in intact RBCs with surrounding edema
- T1WI – hematoma isointense, low signal intensity (SI) edema
- T2WI – hematoma decreased SI at center, high SI edema
Subacute – 2-14 days (BB)
- deoxyhemoglobin changes to methemoglobin from outer to inner
- T1WI – outer core shows increased SI
- T2WI – Outer core shows increased SI due to shortened T1, longer T2
Chronic – 14 days (BB => DD)
- hemosiderin laden macrophages at periphery
- T1WI – inner core now also increased SI, rim has low SI
- T2WI – inner core also has increased SI, rim has low SI
Chronic – months later (DD)
- hemosiderin laden macrophages at periphery
- T1WI – mostly iso-/decreased SI, rim has lower SI
- T2WI – markedly hypointense rim has low SI – “blooms” with greater
T2-weighting
COMMENT: T1WI = T 1 weighted image T2WI = T 2 weighted image SI = signal
intensity

CT PROGRESSION OF ISCHEMIC INFARCT
Initially – 30 HU
1 day – CAUSES OF SUBARACHNOID HEMORRHAGE
Trauma (most common, but different clinical presentation)
* Ruptured aneurysm (classic “Worst HA of my life!”)
* Arteriovenous malformation
Neoplasm
Hypertensive hemorrhage (after rupture through brain or ventricle)
COMMENT: CT identifies a subarachnoid hemorrhage in upto 80 – 95% of cases.
A negative CT does not rule out a small subarachnoid hemorrhage – therefore LP
needed with classiscHx.
SAH => angiogram. If 1st angio negative (spasm, clot, etc) then follow-up angio
in 2-4 wks.
After 2 normal angio => workup spine for source of blood (e.g. spinal AVM,
spinal neoplasm (ependymoma)).

SUBDURAL vs. EPIDURAL
Subdural
- Crescentic shape
- Can layer along falx or tentorium
- Acute 1-7 d
- dense on CT
- MRI isointense on T1WI, decreased on T2W
- Subacute 7-21 d
- isodense on CT
- MRI increased on T1WI and T2WI
- Chronic >21 d
- hypodense on CT, may have enhancing rim
- MRI decreased intensity on T1WI, isointense on T2WI
Epidural
- Biconcave (lenticular)
- Does not cross cranial sutures (unless Fx crosses or previous surgery)
- OUTSIDE (external) to dural sinus
- middle fossa common (laceration of middle meningeal artery)
- may occur in posterior fossa after Fx lacerates transverse sinus


INTRAVENTRICULAR TUMOR

Colloid cyst
- often at foramen of Munro (3rd ventricle)
- hyperdense and enhancing
Choroid plexus papilloma
- usually in lateral ventricles in infants
- more often in 4th ventricle in adults
Meningioma
- uncommonly
Ependymoma
- 4th ventricle
Metastasis – to choroid plexus
Subependymal Giant Cell Astrocytoma (f. of Monro, attach to caudate, 90% have
Tuberous Sclerosis)
Astrocytoma
Central Neurocytoma (usually attached to septum pellucidum)
COMMENT: Both CPP and Meningioma arise within choroid, and derive blood supply
from choroid vessels.


3rd VENTRICULAR MASS

Anterior
- Colloid cyst
- Meningioma
- Ependymoma
- Choroid plexus papilloma (least common location)
- AVM (unusual)
- Basilar artery aneurysm (exotic)
Posterior
- Pineal region tumors (see below)
- Tectal glioma
- Epidermoid
- Meningioma
COMMENT: The 3rd ventricle is least common location for ependymoma and CPP.

PINEAL REGION TUMOR
Germ cell origin (about 60%)
- Germinoma
- 40 – 50% of ALL pineal region tumors
- 2/3 of all Germ-cell origin tumors
- tumor surrounds calcified gland
- homogeneous, dense on plain CT
- Teratoma
- heterogeneous
- may have fat/lipid
- Teratocarcinoma
- Embryonal cell/yolk sac/choriocarcinoma
Pineal parenchymal tumors
- exploded calcification
- radiosensitive
- Pineocytoma
- hyperdense
- Pineoblastoma – very malignant, a type of PNET
Tectal glioma
Meningioma (falx, tentorium)
Metastasis
Vein of Galen Malformation (including aneurysmal dilatation of vein of Galen)

EXTRA-AXIAL TUMORS
Meningioma
- parasagittal > convexities > sphenoid ridge > subfrontal > juxtasellar >
tentorial > posterior fossa > floor of middle cranial fossa
Epidermoid
- Dermoid
- Lipoma (midline, ALL fat, may have callosal agenesis)
Arachnoid cyst
Bony lesion
Meningeal infiltration by lymphoma or leukemia (may look epidural/subdural in
shape) Carcinomatous meningitis

SUPRATENTORIAL TUMOR
Glioma (30-40%)
- Glioblastoma (astro grade IV)
- Astrocytoma
- Oligodendroglioma
- Ependymoma
Metastasis (20-30%)
Meningioma (16%)
Pineal gland tumors
Lymphoma


BASAL GANGLIA CALCIFICATIONS

Birth anoxia
Idiopathic (most common) bilateral and symmetrical
Radiation TX
Toxoplasmosis / CMV – usually not limited to basal ganglia
Hypoparathyroidism / pseudohypoparathyroidism
Infarct
COMMENT: * BIRTH *

SUPRASELLAR MASS
(“SATCHMOE” – nickname for Louis Armstrong, deceased jazz musician
extraordinaire)
Sellar/Parasellar neoplasm
- pituitary adenoma
Aneurysm – sharply marginated – densely enhancing on CT, “pulsation artifact” on
MR
Germ Cell tumor (“ectopic pinealoma” – a misnomer)
Teratoma – heterogeneosu,iso-/lipid – small – solid
Craniopharyngioma – children>adults – calcified 75% – cystic 75%
Hypothalamic glioma – children /
Histiocytosis (Diabetes Insipidus)
Meningioma / metastasis
Optic glioma – erodes sphenoid – visual loss
Epidermoid/Dermoid inclusion cyst
COMMENT: For parasellar mass, add carotid-cavernous fistula and cavernous or
other carotid aneurysm

SELLAR MASS
Pituitary adenoma
Craniopharyngioma
Meningioma
Metastasis
Epidermoid
Abscess
Aneurysm
Pituitary bleed – apoplexy (post-partum or into adenoma)
Pituitary sarcoid
Rathke cleft cyst (usually intrasellar, may extend out)
Germinoma


RING ENHANCING LESION (CT)

Primary brain tumor (glioblastoma) – irregular thick ring
Metastasis (especially if on ChemTx)
Abscess
- ring is more smooth and regula
r – thinner on medial (WM) side
Multiple sclerosis – in white matter
Resolving hematoma – 10-21 days – usually has perilesional lucency
Tuberculoma – associated extracranial TB often found – irregular ring
Infarct
Radiation necrosis – 9 months-3 years after Rtx > 4000 rads
Postoperative change (at edges of resection)
Aneurysm – due to intraluminal thrombus

LOW DENSITY MASS LESION (CT)
Lipoma – (-) CT # (- 60 -90 HU, not merely low, but very low)
Epidermoid – due to inclusion of ectoderm
- often lateral, occasional midline
Arachnoid cyst – CSF density/intensity
- most at temporal tip/ middle fossa P
orencephalic cyst (brain defect)
Infarct (acute from edema, chronic from encephalomalacia)
Pilocytic astrocytoma (cyst fluid)
Ventricle/cistern
Chronic subdural


HYPERDENSE LESION WITHOUT CONTRAST

Meningioma
- 20% also show hyperostosis
- 2/3 show peritumoral edema
Lymphoma (small round blue-cell tumor – densely cellular)
- primary is usually intraaxial
- secondary is often extraaxial
Metastasis – * MRCT * Melanoma/Renal cell Ca/Choriocarcinoma/Thyroid
Medulloblastoma (small round blue-cell tumor – densely cellular)
Glioblastoma
Ependymoma
Colloid cyst (inspissated mucus)
Hemorrhage (acute) / hemorrhagic infarct
Craniopharyngioma
Germinoma (pineal and suprasellar)

MULTIPLE ENHANCING LESIONS
Hematogenous:
Metastases
- 45 -55% of CNS mets multiple
- >2cm often cavitate
- usually near gray-white junction (peripheral > central)
Lymphoma
- usually deeper, periventricular, may be rings in
AIDS Disseminated infection (multiple abscesses)
Multifocal infarction
Inflammatory/Unknown Etiology:
Multiple Sclerosis (white matter lesions)
Vasculitis
Hypertensive Crisis/Ecclampsia
Inherited Mass Lesions/Neoplasms:
Hemangioblastoma (von Hippel-Lindau)
Arteriovenous malformations (cavernous hemangioma >> AVM) Meningiomas – 4% are
multiple (some with NF-2, most without)
Multicentric gliomas – 5% of all gliomas
Tuberous sclerosis
Neurofibromatosis (both types – NF1 (von Recklinhausen) and NF2 (MISME)

GYRAL ENHANCEMENT:
* Ischemia/Infarction (incl. seizures, migraines, etc.)
* Cerebritis/Encephalitis (e.g. Herpes)
Meningeal carcinomatosis (carcinomatous meningitis)
Meningitis – chronic > acute
AVM
Cortical vein thrombosis
Lymphoma
Meningioangiomatosis (NF2)
COMMENT: Sturge-Weber will be dense without contrast due to tram track
calcification in cortex underlying a meningeal venous angioma


CAUSES OF HYDROCEPHALUS (literally “water on the HEAD”)

Communicating (decreased reabsorption)
- Normal pressure hydrocephalus
- prominent temporal horns
- s/p infection – meningitis
- s/p subarachnoid hemorrhage
- Dural vein thrombosis
Non-communicating (mechanical obstruction to flow)
- Aqueductal stenosis
- postinflammatory or congenital
- Tumors – especially colloid cyst
- Congenital anomalies
- Dandy-Walker cyst of 4th ventricle
- Arnold-Chiari malformation
Overproduction (increased production)
- Choroid plexus papilloma
COMMENT: Mimicked by atrophy – “hydrocephalus ex vacuo”

MIDLINE SHIFT
Intracranial mass
- Tumor
- Large infarct with edema
- Intracerebral bleed
Extracerebral collection
- Epidural hematoma
- Subdural hematoma
- Empyema
Unilateral atrophy


HYDROCEPHALUS vs. ATROPHY (CT)

Hydrocephalus (ventricles >> sulci)
- Ballooned and tight frontal horns – Dilated temporal horns
- Dilated 3rd (hourglass shape) with flow void on MR
- decreased mammillopontine measurement (expanded 3rd pushes mammillary bodies
post./inf.
- Dilated 4th ventricle
- Periventricular abnormal signal/density
Atrophy (sulci and ventricles dilate proportionately)
- Large cortical sulci
- Less 3rd ventricular dilatation (with parallel sides NOT hourglass shape)
- Increased with age
COMMENT: Normal pressure hydrocephalus evaluated by nuclear cisternogram. No
migration of activity over convexities/persistent intraventricular activity …
50% aided by shunt (“shunt responsive NPH”)

APPROACH TO INTERPRETATION OF ANGIOGRAPHY
What view (lateral, frontal, oblique, submental-vertex, etc)?
What Vessel Was Injected?
What phase (arterial, capillary, venous) of injection?
Localize lesion (hypervascular/hypovascular, mass effect?, shift?)
Check vessels for displacement
- don’t forget extracerebral lesions
AP – Anterior cerebral arteries, pericallosal
- Internal cerebral veins
- Sylvian point
LAT – Sylvian triangle
POSTERIOR CIRCULATION (verterbral injection)
- Precentral cerebellar vein
- PICA
Characterize vascularity – increased (Hyper) or decreased (Hypo)


BRANCHES OF INTERNAL CAROTID

Meningohypophyseal trunk (that “Italian artery” Bernasconi-Casanari)
Ophthalmic
Superior hypophyseal
Posterior communicating (infundibulum, connects to PCA)
Anterior choroidal (AChoA – marker for temporal lobe herniation)
Anterior cerebral (ACA)
- Frontopolar
- Callosomarginal
- Pericallosal
Middle cerebral (MCA)
- Lenticulostriate (perforators to basal ganglia)
Internal Carotid (ICA)
- Cervical-Petrous-Cavernous-Supraclinoidsegments

POSTERIOR CIRCULATION BRANCHES
Vertebral
- Muscular (occipital) branches
- Meningeal branch
- PICA Basilar
- AICA
- Superior cerebellar (SCA)
- Posterior cerebral (PCA)
- Posterior communicating
- Posterior choroidal (medial/ and lateral branches)
- Parietoccipital
- Posterior temporal
- Calcarine


EXTERNAL CAROTID BRANCHES

Superior thyroid
Lingual
Facial
Ascending pharyngeal
Occipital
Posterior auricular
Superficial temporal
Internal maxillary
- Middle meningeal (f. spinosum)


DEEP VENOUS DRAINAGE

Anterior septal
Thalamostriate
Internal cerebral veins (paired)
Basal vein(s) of Rosenthal (medial temporal lobe)
Great vein of Galen
Inferior sagittal sinus (free edge of Falx)
Straight sinus
Superior sagittal sinus (don’t forget the “Torcular Herophilus”)
Transverse sinus
Sigmoid sinus
Internal jugular
COMMENT: Superficial drainage is superficial middle cerebral vein, vein of
Trolard and vein of Labbe to superior sagittal sinus

CAUSES OF EARLY DRAINING VEIN – (rapid or short “transit time”)
* Neoplasms – primary or secondary
* AVM Inflammatory lesion
Trauma (hyperemia)
Ischemia
Epileptic focus
Toxic encephalopathy
COMMENT: Definition is vein seen CRANIAL FORAMINA AND CONTENTS
Cribiform plate – CNN-I – Olfactory nerve twigs to nasal vault
Optic canal – CNN-II – Optic nerve and ophthalmic artery
Superior orbital fissure
- III – Oculomotor, IV – Trochlear, V1 – Ophthalmic , VI – Abducens, superior
ophthalmic vein
f. Rotundum – V2 Maxillary
f. Ovale – V3 Mandibular and accessory meningeal artery
f. Spinosum – Middle meningeal artery
f. Internal auditory canal – VII (Facial), VIII (Vestibulo-Cochlear)
f. Jugular – Jugular vein, IX — Glossopharyngeal, X – Vagus, XI- Accessory
f. Hypoglossal – XII Hypoglossal
f. Magnum – Spinal cord, XI Accessory, vertebral arteries, spinal arteries


APPROACH TO INTERPRETATION OF MYELOGRAPHY

Check plain films – for bone destruction, previous surgery, trauma, dysraphism
Contrast used – water-soluble, oily
Filling defects, displacement of sac, cord ?
Compartment involved:
CLASSIC:
Intramedullary (cord lesion)
Extramedullary/Intradural (subarachnoid space)
Extradural (outside the thecal sac)
Conus (How low?)
Roots (Thickend, clumped, displaced?)
Thecal sac (Narrowed? Stenosis?)

INTRAMEDULLARY LESION
Tumors
- Ependymoma (most common, esp in adults)
- Astrocytoma (more common in children/Cx location)
- Medulloblastoma (CSF seeding)
- Lipoma/Dermoid/Epidermoid – especially in dysraphism
- Hemangioblastoma (Von Hippel-Lindau syndrome)
- Metastasis – breast/lung/melanoma
- Syringomyelia/Hydromyelia
- Hematoma Inflammation – myelitis
- AVM-Angioma
Cervical – usually glioma or syrinx
Thoracic – consider teratoma, dermoid, astrocytoma?


EXTRAMEDULLARY/INTRADURAL LESION

Meningioma (most thoracic)
Schwannoma (more common than neurofibroma)
Neurofibroma (erodes bone while extending through neural foramen, usually NF-1)
Drop metastasis – medulloblastoma/ependymoma/pineal dysgerminoma/glioma
Dermoid-Epidermoid (associated with dysraphism ?)
Lipoma – most common location is caudal (also “fatty filum”)
COMMENT: Most tumors in this location are benign

EXTRADURAL LESION
Herniated disc (90% at L4-5 and L5-S1)
Osteophyte
Metastasis (Breast-Lung)
Lymphoma
Meningioma
Primary Bone tumor:
- Chordoma
- Osteosarcoma/blastoma
- Myeloma
- Aneurysmal bone cyst
- Giant cell tumor
Neurofibroma (often w/intradural component)
Dermoid-Epidermoid/Lipoma

SACRAL EXPANSILE LESION
Sacrococcygeal Teratoma (often presents in newborn)
Epidermoid cyst
Chordoma (bulky, lobulated mass with bone destruction)
Dural ectasia – meningocele
Dermoid
Lipoma
Giant cell tumor
Aneurysmal bone cyst

OPTIC NERVE THICKENING
Optic nerve glioma (usually pilocytic, often with NF1)
Optic nerve sheath meningioma (tram track lesion outlines normal size nerve)
Papilledema (dilations of SAS that surrounds nerve)
Optic neuritis (MS-Sarcoid)
Orbital pseudotumor
- near globe
- responds to steroid therapy
- thickens muscles AND tendons
Graves’ disease
- thickens extraocular muscles
- no tendon involvement
Vascular malformations
- cavernous hemangioma > AVM
- carotid-cavernous fistula
Orbital cellulitis – may be 2nd to ethmoid sinusitis Leukemia Perineuritis Optic
nerve hemorrhage
COMMENT: Check optic chiasm for intracranial extension

OCULAR MASS
Child
- Retinoblastoma
- 2/3 “heritable”, 1/3 w/Family Hx
- multiple/bilateral if “heritable”
- 90% Ca++
- staging (vitreous, choroidal, scleral, extension?)
Adult
- Choroidal melanoma
- older patient, enhance
- Metastasis – breast, lung, extra-ocular melanoma
- Intraocular lymphoma
- Choroidal hemangioma

RETRO-OCULAR MASS (Intraconal)
Hemangioma
- enhance – phleboliths seen in 10%
Optic nerve glioma
Optic nerve meningioma
Angioma
Lymphangioma
AVM

CONAL MASS
Rhabdomyosarcoma
- bone destruction
- calcification
Thyrotoxic ophthalmopathy
- 88% bilateral
- 80 % medial, inferior rectus muscles
Myositic pseudotumor

EXTRACONAL MASS
Dermoid Mucocele
- occurrence frontal > ethmoid > maxillary > sphenoid
* FEMS
* Lymphoma
Pseudotumor

LACRIMAL GLAND MASS
Unilateral
- Pleomorphic adenoma (histo similar to minor salivary gland tumors)
- benign
- Malignant epithelial cell tumors
- Adenoid cystic carcinoma
- bone destruction
- Pseudotumor – Dacroadenitis
Bilateral (systemic diseases)
- Lymphoma
- Sarcoid
- Collagen vascular disease


RADIOLUCENT SKULL LESION

Metastasis
Normal variant
Epidermoid (intradiploic)
Eosinophilic granuloma (“beveled” margins)
Plasmacytoma
Paget’s (widened diploic space)
Burr hole
Fibrous dysplasia (widened diploic space)
Hemangioma (widened diploic space, radial or starburst trabeculae)
Brown tumor of hyperparathyroidism
Osteomyelitis
Erosion from intracranial tumor (usu slow-growing, e.g. meningioma,
oligodendroglioma)

OPAQUE PARANASAL SINUS
Acute sinusitis – FLUID
Fracture (blood)
Chronic sinusitis – MUCOSAL THICKENING
Mucocele (obstructed sinus ostium => expanded sinus)
Retention cyst (obstructed mucus gland => round mass)
Polyp
Normal hypoplastic
- OTHER
Cystic fibrosis
Inverting papilloma (bone destruction)
Malignant tumor

EXPANSILE LESION OF SINUS
Fibrous dysplasia
Mucocele
Ossifying fibroma
Extensive polyposis (allergic history?)

PHAKOMATOSES
Tuberous sclerosis
- Autosomal dominant
- Adenoma sebaceum, seizures, mental retardation
- Hamartomas involving many organs, angiomyolipomas of kidneys
- Brain – periventricular subependymal nodules
- Cortical tubers
- 15% develop subependymal giant cell astrocytoma
Sturge-Weber (Encephalotrigeminal angiomatosis )
- No inheritance pattern, congenital malformation
- Port wine nevus of face
- V1 distribution
- Seizures, mental retardation, glaucoma
- CT – gyral calcification and cerebral atrophy
- MR – gyriform enhancement – mass-like choroid plexus
- calvarial/facial thickening
- hemiatrophy and hemiparesis
Von Hippel-Lindau
- Hemangioblastomas – cerebellum, retina, medulla, spinal cord
- Pheochromocytoma (NIH Type 2a or 2b)
- Renal cysts 60%
- Renal cell carcinoma 45%
- Pancreatic cysts, Islet cell tumors, serous adenomas
Von Recklinghausen (Neurofibromatosis Type 1, NF1)
- Autosomal dominant
- Cafe-au-lait spots 6 or more, 15mmm in adult
- fibroma molluscum (multiple cutaneous neurofibromas) – Sphenoid dysplasia -
Acute kyphotic scoliosis
- Lateral thoracic meningocele
Type I – chromosome 17 – “peripheral” type (misnomer)
- Peripheral neurofibromas – Other CNS tumors – glioma, optic glioma
Wishart Neurofibromatosis (Bilateral Vestibular Schwannomas) Type II
- chromosome 22 – “central” type (misnomer)
(aka MISME Syndrome: Multiple Inherited Schwannomas, Meningiomas, and
Ependymomas)
- Bilateral vestibular schwannomas in “all” patients
- Other CNS tumors – meningioma, spinal cord ependymoma, other cranial and
spinal schwannomas
COMMENT: The gliomas of NF-2 are ependymoma, those in NF-1 are astrocytoma
(both pilocytic and glioblastoma)

D/D ‘s IN CHEST DISEASES

Differential diagnoses in Chest diseases

NEONATAL LUNG DISEASES:

Hyaline Membrane Disease
Bronchopulmonary Dysplasia
Meconium Aspiration
Neonatal Pnuemonia – strep B, HSV, CMV
Premi Acclerated Lung Maturation – stress, glucocorticoids
Transient Tachypnea of the Newborn
Congenital Lobar Emphysema
Pulmonary Interstitial Emphysema
Pulmonary Lymphangiectasia

DIFFERENTIAL Dx FOR NEONATAL LUNG
Decreased Lung Vol – HMD
Plueral Effusion – pneumonia, mec aspiration, TTN
Pneumothorax – HMD, mec aspiration
Normal Heart Size w edema – TAPVR III, TTN, pulmonary lymphagiectasia

CHEST WALL DENSITY
Skin – nipple, mole
Soft Tisssue Noplasm – lipoma, neural, askin
Bone Neoplasm – myeloma, chondrosarcoma, ewings
Trauma – hematoma, fractures
Infection – actinomycosis, TB

PLUERAL DENSITIES
Loculated Effusion – CHF, infection
Mets – multiple, thymoma
Mesothelioma – benign has pedicle, malig no plaques assoc
Lipoma
Splenosis – assoc with trauma

PNEUMOTHORAX
Trauma
Ventilator
Eosinophilic Granuloma
Lymphangiomyomatosis
Alveolar Protienosis
Pneumocystis Carini
Osteosarcoma Mets

PLEURAL EFFUSIONS
CHF
PE
Pneumonia – TB
Trauma – chylous, boerhaave’s, aorta
Neoplasm – meig’s
Pericarditis – dressler’s, post-pericardotomy
Abdominal Pathology – pancreatitis, post-surg
Collagen Vascular Diseases – rheumatoid, SLE, wegener’s
Low Colloid Pressure

DIAPHRAGM ELEVATION
Subpulmonic
Pulmonary Volume Loss – atelectasis, venolobar
Nerve Paralysis – phrenic, ALS, myasthenia
Diaphragmatic Abnormality – hernia, eventration
Abdominal Process – abscess, chiliditi

WIDE MEDIASTINUM
Technique
Vascular – ectasia, dissection, coarctation, left SVC
Trauma
Neoplasm
Pneumomediastinum
Mediastinitis – histo
Lipomatosis
Achalasia – look for AF levels

SHIFT OF THE MEDIASTINUM
Decreased Lung Volume
Increased Lung Volume – FB, bronchogenic cyst, CAM, swyer-james
Plueral Space Abnormality – effusion, pneumo, diaphragmatic hernia
Partial Absent Pericardium

ANTERIOR MEDIASTINAL MASS
Thymus
Germ Cell – teratoma, seminoma, choriocarcinoma
Thyroid
Lymphoma
Cardiovascular – aneurysm, pericardial cyst, epicardial fat pad
Cystic Hygroma

MIDDLE MEDIASTINAL MASS
Lymphadenopathy – mets, castleman’s
Neoplasm
Vascular
Achalasia
Duplications – bronchogenic cyst, sequestration

POSTERIOR MEDIASTINAL MASS
Neural – nerve root tumors, gangliomas, paragangliomas, lat meningocele
Duplication – enteric, neurenteric cysts
Inflammation – paraspinous abcess, sarcoid
Hematoma – trauma
Extramedullary Hematopoesis

HILAR ENLARGEMENT
Bronchogenic Carcinoma
Lymphoma
Sarcoid
TB
Histo
Pneumoconiosis


TRACHEAL MASSES

Squamous Cell
Adenoid Cystic – cylindroma
Carcinoid – “iceberg”
Chondroma
Fibroma
Papilloma – aquired at birth
Hemangioma – children


TRACHEAL NARROWING

Saber Sheath
Postintubation Stenosis
Relapsing Polychondritis
Amyloidosis
Tracheobronchopathia Osteochondroplastica – benign calc nodules

TRACHEAL DILATION
Mounier-Kuhn Syn
Tracheobronchomalacia
Ehler’s-Danlos Syn

ATELECTASIS
Obstructive – bronchial neoplasm, inflammatory, FB
Passive – plueral process
Compressive – intraparenchymal mass, air trapping
Adhesive – PE, hyaline membrane Dz
Cicatrization

AIRSPACE CONSOLIDATION
Blood – trauma, DIC, PE, vasculitis, hemosiderosis
Pus – bacteria, PCP, fungus, TB
Fluid – CHF, renal failure, toxic inhalation, ARDS
Cells – bronchoalveolar Ca, lymphoma
Protien – alveolar portienosis, mucus plug

SEGMENTAL CONSOLIDATION
Lobar Pneumonia
Bronchopneumonia
Interstitial Pneumonia – viral, mycoplasm
Aspiration
TB & Atypical Mycobacterium
Trauma
Pulmonary Embolism
Obstructing Neoplasm
Mitral Regurgitation


ADULT RESPIRATORY DISTRESS SYNDROME

Event
White Out
Loss of Compliance
Refractory Hypoxemia
Shunt – precapillary

PULMONARY VASCULITIS
Infectious – RM spotted fever, mucormycosis
Wegener’s – diffuse, cavitate, nasal, 40+yrs, 2:1 male
Goodpasture’s – perihilar, hemoptysis, 25yrs, 7:1 male
SLE

PATTERNS OF INTERSTITIAL DISEASE
Septal Lines – CHF, lyphangitic Ca
Reticular (irregular lines) – UIP, sarcoid, asbestos, drug
Air Cysts (round) – UIP, PCP, LAM, EG, bronchiectasis
Nodules – sarcoid, silicosis, EG, EAA (extrinsic allergic alveolitis)
Ground Glass Opacities – DIP, PCP, EAA, alveolar proteinosis
Hyperinflation – LAM, EG, CF, or any w COPD

LOWER LOBE INTERSTITIAL DISEASES (mnemonic: badd lass rf)
Bronchiectasis
Aspiration
DIP – desquamative interstitial pneumonitis
Dermatomyositis
Lymphangitic spread
Asbestosis
Scleroderma
Sarcoid
Rheumatoid Lung
Furadantin

UPPER LOBE INTERSTITIAL DISEASES (casset)
Cystic Fibrosis
Ankylosing Spondylitis
Silicosis
Sarcoid
Eosinophilic Granuloma
TB

BRONCHIECTASIS (saccular & cylindrical types)
Infectious – aspergilla, TB, Sweyer-James
Congenital – cystic fibrosis, Kartagner syn, agammaglobulinemia
Obstructive – neoplasm, nodes
Chemical – aspiration, inhalation
Fibrotic – COPD

SOLITARY PULMONARY NODULE
Bronchogenic Ca
Hamartoma
Granuloma
AVM
Abcess

CAVITATING PULMONARY NODULES
Infection – staph, klebsiella, TB, coccidiomycosis, septic emboli, PCP
Neoplasm – squamous cell ca, osteosarcoma
Vasculitis – wegener’s, rheumatoid
Trauma – pneumatoceles
Bronchogenic Cyst
Pulmonary Embolism

PULMONARY CALCIFICATION
TB
Histo
Silicosis
Alveolar Microlithiasis
Hyperparathyroidism
Chronic Venous Congestion – mitral stenosis
Treated Lymphoma
Idiopathic Pulmonary Osteopathy

UNILATERAL HYPERLUCENT LUNG
Chest wall defect – mastectomy, absent pectoralis
PE – westmarks sign
FB – obstuctive emphysema
Pulmonary hypoplasia
Sweyer-James

AORTIC ANEURYSMS
Atherosclerosis – abd
Marfan’s
Vasculitis – Syphilis, Takayasu, Kawasaki, fungal, TB, polyarteritis nodosa
Aortic Valve Stenosis – asc dilation

CAUSES OF RIB NOTCHING
Coarctation
Aortic Thrombosis
Subclavian Obs – Blalock shunt for tricuspid atresia
Pulmonary Oligemia – any cause of dec flow

CARDIOMEGALY
Highoutput Failure – vein of Galen aneurysm, AVM etc
Outflow Obstruction Failure
Cardiomyopathy
Pericardial Effusion – always rule out

PULMONARY ARTERIAL HYPERTENSION
Primary
Lung Disease – COPD
Multiple PE
Eisenmienger

EMPHYSEMA TYPES
Centrilobular – #1, smoker, upper
Panacinar – alpha-1-antitrypsin, diffuse
Paraseptal – peripheral blebs

RADIOLOGICAL TERMS IN DEGENERATIVE DISC DISEASE:

RADIOLOGICAL TERMS IN DEGENERATIVE DISC DISEASE:

Aging disc: Disc demonstrating the features of normal aging. Spondylosis deformans possibly represents the normal aging process.

Anterior displacement: Displacement of disc tissues beyond the disc space into the anterior zone.

Annulus, (abbreviated form of annulus fibrosus): A multilaminated ligament surrounding the periphery of each disc space, attaching, craniad and caudad, to end-plate cartilage and ring apophyseal bone and blending centrally with nucleus pulposus. Note: Either anulus or annulus is correct spelling. Nomina Anatomica uses both forms whereas Terminologia Anatomica states “annulus fibrosus.” Fibrosus, has no correct alternative spelling; fibrosis has a different meaning and is incorrect in this context.

Asymmetric bulge: Presence of outer annulus beyond the plane of the disc space, more evident in one section of the periphery of the disc than another, but not sufficiently focal to be characterized as a protrusion. Note: Asymmetric bulge is a morphologic observation of various potential causes and is not a diagnosis. See: bulge.

Balloon disc (colloquial): Diffuse displacement of nucleus through the vertebral end plate, commonly seen in severe osteoporosis.

Base (of displaced disc): The cross sectional area of disc material at the outer margin of the disc space of origin, where disc material displaced beyond the disc space is continuous with disc material within the disc space. In the cranio-caudal direction, the length of the base cannot exceed, by definition, the height of the intervertebral space.

Broad-based protrusion: Herniation of disc material extending beyond the outer edges of the vertebral body apophyses over an area greater than 25% (90 degrees) and less than 50% (180 degrees) of the circumference of the disc. See protrusion. Note: Broad based protrusion refers only to discs in which disc material has displaced in association with localized disruption of the annulus and not to generalized (over 50% or 180 degrees) apparent extension of disc tissues beyond the edges of the apophyses. If the base is less than 25%, it is called “focal protrusion.” Apparent extension of disc material, formation of additional connective tissue between osteophytes, or overlapping of non-disrupted tissue beyond the edges of the apophyses of over 50% of the circumference of the disc may be described as bulging. See: bulging disc, focal protrusion.

Bulging disc, bulge (n), bulge (v): 1. A disc in which the contour of the outer anulus extends, or appears to extend, in the horizontal (axial) plane beyond the edges of the disc space, over greater than 50% (180 degrees) of the circumference of the disc and usually less than 3mm beyond the edges of the vertebral body apophyses. 2. (Non-Standard) [A disc in which the outer margin extends over a broad base beyond the edges of the disc space.] 3. (Non-Standard) [Mild, smooth displacement of disc, whether focal or diffuse.] 4. (Non-Standard) [Any disc displacement at the discal level.] >Note: Bulging is an observation of the contour of the outer disc and is not a specific diagnosis. Bulging has been variously ascribed to redundancy of annulus secondary to loss of disc space height, ligamentous laxity, response to loading or angular motion, remodeling in response to adjacent pathology, unrecognized and atypical herniation, and illusion from volume averaging on CT axial images. Bulging may or may not represent pathologic change, physiologic variant, or normalcy. Bulging is not a form of herniation; discs known to be herniated should be diagnosed as herniation or, when appropriate, as specific types of herniation. See: herniated disc, protruded disc, extruded disc.
Capsule: Combined fibers of annulus and posterior longitudinal ligament. Note: The interface between outer annulus and posterior longitudinal ligament can be indistinguishable, making useful the term “capsule” and the derivative “sub-capsular,” which refers to disc tissue beneath the capsule.

Central zone: Zone within the vertebral canal between sagittal planes through the medial edges of each facet. Note: The center of the central zone is a sagittal plane through the center of the vertebral body. The zones to either side of the center plane are right central and left central, which are preferred terms when the side is known, as when reporting imaging results of a specific disc. When the side is unspecified, or grouped with both right and left represented, the term paracentral is appropriate.

Chronic disc herniation: 1. Disc herniation with presence of calcification, ossification, or gas accumulation within the displaced disc material, suggesting that the herniation is not of recent origin. Note: The term implies the presence of calcification, ossification, or gas accumulation and should not be used for herniations of soft disc material, regardless of the duration of displacement. See: degenerated disc, hard disc.

Claw osteophyte: Bony outgrowth arising very close to the disc margin, from the vertebral body apophysis, directed, with a sweeping configuration, toward the corresponding part of the vertebral body opposite the disc.

Communicating disc, communication (n), communicate (v): Interruption in the periphery of the disc, so that fluid injected into the disc space could flow into the vertebral canal and thus into contact with displaced disc material. Note: Communication refers to the status of displaced disc tissues with reference to the parent disc. Containment refers to the integrity of the annulus as container of disc tissues. Uncontained, displaced disc tissues could be noncommunicating if the displaced tissue is sealed off by peridural membrane or by healing of the tear in the annulus.

concentric tear: Tear or fissure of the annulus characterized by separation, or break, of anular fibers, in a plane roughly parallel to the curve of the periphery of the disc, creating fluid-filled spaces between adjacent anular lamellae. See: radial tears, transverse tears.
Contained herniation, containment (n), contain (v): 1. Displaced disc tissue that is wholly within an outer perimeter of uninterrupted outer annulus or capsule. 2. (Non-standard) [A disc with its contents mostly, but not wholly, within annulus or capsule.] 3. (Non-Standard) [A disc with displaced elements contained within any investiture of the vertebral canal.] Note: The preferred meaning encompasses disc tissues that are enclosed by distended portions of the outer annulus or composite of fibers of the annulus and posterior longitudinal ligament. A disc whose substance is less than wholly contained by annulus is uncontained, as is a disc outside of anular fibers but under a distinct posterior longitudinal ligament or peridural membrane. Designation of a disc as contained, or uncontained, should define the integrity of the annulus enclosing the disc, though such distinction may not be possible with currently available imaging modalities.

Continuity: 1. Connection of displaced disc tissue by a bridge of disc tissue, however thin, to tissue within the disc of origin. 2. (Non-Standard) [Connection of displaced displaced disc tissue by a substantial bridge of disc tissue to disc within the disc of origin]. 3. (Non-Standard) [Connection of displaced disc tissue by any tissue to disc tissue within the disc or origin.] Note: Tenuous attachments, beyond recognition by most imaging methods, may have significance to the surgeon or endoscopist. Bridges of peridural membrane, or scar, do not represent continuity. See sequestration.

degenerated disc, degeneration (n), degenerate (v): 1. Changes in a disc characterized by desiccation, fibrosis and cleft formation in the nucleus, fissuring and mucinous degeneration of the annulus, defects and sclerosis of end-plates, and/or osteophytes at the vertebral apophyses. 2. Imaging manifestations commonly associated with such changes. 3. (Non-Standard) [Changes in a disc related to aging.] Note: Either of the first two definitions may be correct, depending upon context. Clinical features must be considered to determine whether degenerative changes are pathologic and what may or may not have contributed to their development. The term degenerated disc, in itself, does not infer knowledge of cause, relationship to aging, presence of symptoms, or need for treatment. See intervertebral osteochondrosis, spondylosis, spondylosis deformans.

Degenerative disc disease(DDD): 1. A clinical syndrome characterized by manifestations of disc degeneration and symptoms thought to be related to those changes. 2. (Non-Standard) [Abnormal disc degeneration.] 3. (Non-Standard) [Imaging manifestations of degeneration greater than expected, considering the age of the patient]. Note: Causal connections between degenerative changes and symptoms are often difficult clinical distinctions. The term carries implications of illness that may not be appropriate if the only manifestations are from imaging. The preferred term for description of imaging manifestations alone, or imaging manifestations of uncertain relationship to symptoms, is degenerated disc rather than degenerative disc disease.

Delamination: Separation of anular fibers along planes parallel to the periphery of the disc, thought to represent separation of laminated layers of the outer anulus fibrosus.

Desiccated disc: 1. Disc with reduced water content, usually primarily of nuclear tissues. 2. Imaging manifestations of reduced water content of the disc; or apparent reduced water content, as from alterations in the concentration of hydrophilic glycosaminoglycans.

Disc (disk): Complex structure composed of nucleus, anulus, cartilaginous end-plates, and vertebral body ring apophyseal attachments of anulus. Note: Most English language publications use the spelling disc more often than disk.12 Nomina Anatomica designates the structures as “Disci intervertebrales” and Terminologia Anatomica as “discus intervertebralis/Intervertebral disc.”18,21

Disc of origin: Disc from which a displaced fragment originated. Syn: parent disc. Note: Since displaced fragments often contain tissues other than nucleus, disc of origin is preferred to nucleus of origin. “Parent disc” is synonymous, but more colloquial.

Disc space: 1. Space limited, craniad and caudad, by the end-plates of the vertebrae and peripherally by the edges of the vertebral body ring apophyses exclusive of osteophytes. Syn: intervertebral disc space.

Discogenic vertebral sclerosis: Increased bone density and calcification adjacent to the end-plates of the vertebrae craniad and caudad to a degenerated disc, usually a manifestation of intervertebral osteochondrosis.


Displaced disc:
A disc in which disc material is beyond the outer edges of the vertebral body ring apophyses (exclusive of osteophytes) of the craniad and caudad vertebrae, or, as in the case of intravertebral herniation, penetrated through the vertebral body end-plate. Note: Displaced disc is a general term that does not imply knowledge of the underlying pathology, cause, relationship to symptoms, or need for treatment. The term includes, but is not limited to, disc herniation and disc migration.See: herniated disc, migrated disc.


Extra-foraminal zone:
The zone beyond the sagittal plane of the lateral edges of the pedicles, having no well-defined lateral border. Syn: far lateral zone, far-out zone.

Extra-ligamentous: Posterior or lateral to the posterior longitudinal ligament. Note: Extra-ligamentous disc refers to displaced disc tissue that is located lateral, or posterior to the posterior longitudinal ligament. If the disc has extruded through the posterior longitudinal ligament it is sometimes called “trans-ligamentous” or “perforated,” and if through the peridural membrane, it is sometimes refined to as “trans-membranous.”

Extruded disc, extrusion (n), extrude (v): A herniated disc in which, in at least one plane, any one distance between the edges of the disc material beyond the disc space is greater than the distance between the edges of the base in the same plane, or when no continuity exists between the disc material beyond the disc space and that within the disc space. Note: The preferred definition is consistent with the common language image of extrusion as an expulsion of material from a container through and beyond an aperture. Displacement beyond the outer anulus of disc material with any distance between its edges greater than the distance between the edges of the base distinguishes extrusion from protrusion. Distinguishing extrusion from protrusion by imaging is best done by measuring the edges of the displaced material and remaining continuity with the disc of origin, whereas relationship of the displaced disc material to the aperture through which it has passed is more readily observed surgically. Characteristics of protrusion and extrusion may co-exist, in which case the disc should be subcategorized as extruded. Extruded discs in which all continuity with the disc of origin is lost may be further characterized as sequestrated. Disc material displaced away from the site of extrusion may be characterized as migrated. See: herniated disc, migrated disc, protruded disc.

Fissure of anulus: Separations between anular fibers, avulsion of fibers from their vertebral body insertions, or breaks through fibers that extend radially, transversely, or concentrically, involving one or more layers of the anular lamellae. Syn: tear of anulus, torn anulus. Note: The terms fissure and tear are commonly used synonymously. Neither term implies any knowledge of etiology, relationship to symptoms, or need for treatment. Tear or fissure are both used to represent separations of anular fibers from causes other than sudden violent injury to a previously normal anulus, which can be appropriately termed “rupture of the anulus,” which, in turn, contrasts to the colloquial, non-standard, use of the term “ruptured disc,” referring to herniation.
Focal protrusion: Protrusion of disc material so that the base of the displaced material is less than 25% (90 degrees) of the circumference of the disc. Note: Focal protrusion refers only to herniated discs that are not extruded and do not have a base greater than 25% of the disc circumference. Herniated discs with a base greater than 25% are “broad-based protrusions.”

Foraminal zone: The zone between planes passing through the medial and lateral edges of the pedicles. Note: The foraminal zone is sometimes called the “pedicle zone,” which can be confusing because pedicle zone might also refer to measurements in the sagittal plane between the upper and lower surface of a given pedicle, which is properly called the “pedicle level.” The foraminal zone is also sometimes called “lateral zone,” which can be confusing because lateral zone can also mean extra-foraminal zone or an area including both the foraminal and extra-foraminal zones.

Free fragment: 1. A fragment of disc that has separated from the disc of origin and has no continuous bridge of disc tissue with disc tissue within the disc of origin. Syn: sequestrated disc . 2. (Non-Standard) [A fragment that is not contained within the outer perimeter of the anulus.] 3. (Non-Standard) [A fragment that is not contained within anulus, posterior longitudinal ligament, or peridural membrane.] Note: Sequestrated disc and free fragment are virtually synonymous. When referring to the condition of the disc, categorization as extruded with sub-categorization as sequestrated is preferred, whereas free fragment or sequestrum is appropriate when referring specifically to the fragment.

Hard disc: Disc displacement in which the displaced portion has undergone calcification or ossification and may be intimately associated with apophyseal osteophytes. Note: The term hard disc is most often used in reference to the cervical spine to distinguish chronic hypertrophic and reactive changes in the periphery of the disc from acute extrusion of soft, predominantly nuclear tissue. See: chronic disc herniation.

Herniated disc, herniation (n), herniate (v): 1. Localized displacement of disc material beyond the normal margins of the intervertebral disc space. 2. (Non-Standard) [Any displacement of disc tissue beyond the disc space]. Note: Localized means, by way of convention, less than 50% (180 degrees) of the circumference of the disc. Disc material may include nucleus, cartilage, fragmented apophyseal bone, or fragmented anular tissue. The normal margins of the intervertebral disc space are defined, craniad and caudad, by the vertebral body end-plates and peripherally by the edges of the vertebral body ring apophyses, exclusive of osteophytic formations. Herniated disc generally refers to displacement of disc tissues through a disruption in the anulus, the exception being intravertebral herniations (Schmorl’s nodes) in which the displacement is through vertebral end-plate. Herniated discs in the horizontal (axial) plane may be further subcategorized as protruded or extruded. Herniated disc is sometimes referred to as “herniated nucleus pulposus,” but the term herniated disc is preferred because displaced disc tissues often include cartilage, bone fragments, or anular tissues. The term “ruptured disc” is used synonymously with herniated disc, but is more colloquial and can be easily confused with violent, traumatic rupture of the anulus or end-plate. The term “prolapse” has also been used as a general term for disc displacement, but its use has been inconsistent. The term herniated disc does not infer knowledge of cause, relation to injury or activity, concordance with symptoms, or need for treatment.

High intensity zone (HIZ): Area of high signal intensity on T2-weighted magnetic resonance images of the disc, usually referring to the outer anulus. Note: High intensity zones within the posterior anular substance may reflect fissure or tear of the anulus, but do not imply knowledge of etiology, concordance with symptoms, or need for treatment.

infra-pedicular level: The level between the axial planes of the inferior edge of the pedicle craniad to the disc in question and the inferior end-plate of the vertebral body above. Syn: superior vertebral notch.
Internal disc disruption syndrome: Internal disc disruption associated with symptoms, which are thought, on clinical grounds, to be caused by the disruption. Syn: Crock disc.

Intervertebral osteochondrosis: Degenerative process of the spine involving the vertebral body end-plates, the nucleus pulposus, and the anulus fibrosus, which is characterized by disc space narrowing, vacuum phenomenon, and vertebral body reactive changes. Syn: deteriorated disc, chronic discopathy, osteochondrosis.

Intra-anular displacement: Displacement of central, predominantly nuclear, tissue to a more peripheral site within the disc space, usually into a fissure in the anulus. Syn: (Non-Standard) [intra-anular herniation], [intra-discal herniation]. Note: Intra-anular displacement is distinguished from disc herniation, in that herniation of disc refers to displacement of disc tissues beyond the disc space. Intra-anular displacement is a form of internal disruption. When referring to intra-anular displacement, it is best not to use the term “herniation” in order to avoid confusion with disc herniation.
Intra-dural herniation: A disc from which displaced tissue has penetrated, or become enclosed by, the dura so that it lies within the thecal sac.
Intra-vertebral herniation: A disc in which a portion of the disc is displaced through the end-plate into the centrum of the vertebral body. Syn: Schmorl’s node.

limbus fracture: Traumatic separation of a segment of bone from the edge of the vertebral ring apophysis at the site of anular attachment. Note: Limbus fractures of various types may be accompanied by disc herniation, usually by either focal or broad-based protrusion. They may occur into the anterior zone or posteriorly into the zones where they may compress neural tissues.

Limbus vertebrae: Separation of a segment of rim of vertebral body ring apophysis. Note: Limbus vertebrae may result from fracture or from developmental abnormalities. Limbus vertebrae is commonly seen in patients who have had Scheuermann’s Disease. The lesions may be called “rim lesions.” The term is derived from the Latin nominative limbus and genitive modifier vertebrae, thus is singular.

Marginal osteophyte: Osteophyte that protrudes from and beyond the outer perimeter of the vertebral end-plate apophysis.
Migrated disc, migration (n), migrate (v): 1. Herniated disc in which a portion of extruded disc material is displaced away from the tear in the outer anulus through which it has extruded. 2. (Non-Standard) [A herniated disc with a free fragment or sequestrum beyond the disc level.] Note: Migration refers to the position of the displaced disc material, rather than to its continuity with disc tissue within the disc of origin; therefore, it is not synonymous with sequestration.

non-marginal osteophyte: Osteophyte the occurs at sites other than the vertebral end-plate apophysis. See: marginal osteophyte.

Normal disc: 1. A fully and normally developed disc with no changes attributable to trauma, disease, degeneration, or aging. The bilocular appearance of the adult nucleus is considered a sign of normal maturation. 2. (Non-Standard) [A disc that may contain one or more morphologic variants which would be considered normal given the clinical circumstances of the patient.]. Note: Many congenital and developmental variations may be normal in that they are not associated with symptoms; certain adaptive changes in the disc may be normal considering adjacent pathology, and certain degenerative phenomena may be normal given the patient’s age; however, classification and reporting for medical purposes is best served if such discs are not considered normal. What is clinically normal for a given patient is a clinical judgment independent of the need to describe any variation in the disc itself.

Osteophytes: Focal hypertrophy of bone surface and/or ossification of soft tissue attachments to the bone.

TELERADIOLOGY

TELE-RADIOLOGY:

Teleradiology is a method of distributing digital diagnostic images such as, X-rays, ultrasonography, magnetic resonance and radioisotopes, and other related information through local area or wide area networks between remotely located facilities.

A well planned teleradiology system can be a cost effective and time efficient method that allows users to capture, transmit, store, and review patient studies. In design and implementation of a successful teleradiology system the following categories play a significant role:

Storage Systems And Databases (PACS)

Picture Archiving and Communication System (PACS) is an image-based information system for the acquisition, storage, communication, archiving, display, and manipulation of medical digital images, and other relevant data. The PACS archive is expected to replace radiology film library.

Imaging Standards (DICOM)

A practical archive system must be capable of moving the data off onto its successor system. DICOM (Digital Imaging Communication) is an imaging standard that allows the exchange of data between different hosts and equipment across the network in a heterogeneous environment.

HIS/RIS:

The concepts of PACS and HIS/RIS (Hospital and Radiology Information Systems) are the same; only the data types are different. PACS applications manage images, and HIS/RIS applications manage patients, studies, and results. The coupling of PACS and HIS/ RIS has been repressed due to incompatibility of data definitions and standards. Triggered by user needs, recent developments aim at high level integration of PACS and HIS/RIS.

High Speed Networks

High speed data transmission and data security are crucial prerequisites for the clinical acceptance of distributed medical services. It is widely believed that Asynchronous Transfer Mode (ATM) is a type of networking technology that will make transmission of digital medical images practical and affordable. ATM has the ability to handle large amounts of traffic simultaneously, bandwidth scalability and integration with existing network protocols such as Ethernet, and FDDI.

Video Networks And Multimedia Systems

Providing “real-time interactive” video transfer of ultrasound images can improve efficiency and faster turnaround time for radiographic reports, while maintaining the quality of care. Implementation of the real-time ultrasound video transfer has become possible because of the availability of ATM technology and Advanced Communications Technology Satellite (ACTS). These technologies allow remote real time monitoring of invasive procedures, and remote clinical diagnosis of multiple disease and pathology states which in turn make subspecialty consultation and education at a distance feasible.