Publications by authors named "Atin Kumar"

208 Publications

Imaging in extremity vascular trauma: can MDCT angiography predict the nature of injury?

Emerg Radiol 2022 Apr 25. Epub 2022 Apr 25.

Department of Surgical Disciplines, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India.

Objective: This study aims to evaluate the utility of computed tomography angiography (CTA) signs of vascular injury in the differentiation of vessel transection from pure thrombosis with intact vessel wall.

Methods: Retrospective analysis was done on 146 consecutive patients who had undergone CTA and surgical exploration from January 2015 to September 2019. Twelve imaging parameters were assessed. Chi-square was used to test the difference between groups. In addition, a scoring system was devised where one point each was added for the presence of 5 signs and absence of 3 signs. ROC analysis was done for the variables which had shown significant difference between groups and for the composite score.

Results: On surgical exploration, 87 patients had transection of vessel, while 59 had thrombosis. Significant difference was found among the two groups in non-opacification, pseudoaneurysm, extravasation (p = 0.04 each), thrombosed cord (p < 0.001), collaterals (p = 0.001) and hematoma (p = 0.002), while other signs did not show significant difference. The AUC value for each of these variables was < 0.650, while for the score, AUC was .843(.773-.913). A cut-off value of ≥ 1.5 gave 83.1% sensitivity and 70% specificity for diagnosing transection.

Conclusion: CTA is a useful tool to classify the nature of vascular injury. It is advisable to use a composite score for maximum diagnostic value.
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http://dx.doi.org/10.1007/s10140-022-02050-4DOI Listing
April 2022

Vascular anomalies: nomenclature, classification, and imaging algorithms.

Acta Radiol 2022 Apr 12:2841851221082241. Epub 2022 Apr 12.

Department of Plastic, Reconstructive and Burns Surgery, Department of Radiodiagnosis and Interventional Radiology, 28730All India Institute of Medical Sciences, New Delhi, India.

There is a lot of ambiguity in the usage of correct terminology in the description of vascular malformations and tumors. Hemangioma and arteriovenous malformation (AVM) are the most commonly used terms and are the mostly incorrectly used as well! The aim of this review article was to lay out the correct nomenclature and describe the correct usage for the physicians and radiologists involved in diagnosing and managing these lesions. We describe the various classification systems which have been devised to define the multiple entities included under vascular anomalies. The latest classification system that should be adhered to is per the International Society for the Study of Vascular Anomalies, approved at the 20th ISSVA Workshop held in Melbourne in April 2014, last revised in May 2018. The main features of the latest revision have been highlighted. This classification, however, does not list the diagnostic clinico-radiological features for each entity. In addition, guidelines regarding the appropriate use of available imaging modalities are lacking in the literature. We, hereby, aim to address these pertinent issues in this review article.
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http://dx.doi.org/10.1177/02841851221082241DOI Listing
April 2022

Pulse corticosteroids for the management of extensive CNS tuberculosis presenting with acute-onset quadriparesis.

Drug Discov Ther 2022 May 24;16(2):102-104. Epub 2022 Mar 24.

Department of Medicine, All India Institute of Medical Sciences, Delhi, India.

Myelopathy in central nervous system tuberculosis is notorious for poor outcomes, determined by the severity of inflammation and cord level involved. Acute-onset quadriplegia or paraplegia in these cases represents a neuro-emergency. We report a young female with disseminated tuberculosis who presented with acute onset flaccid quadriparesis with loss of bladder and bowel function. Imaging helped identify the extensive involvement of the neuraxis. We propose that, in addition to anti-tubercular therapy, high-dose corticosteroids such as pulse methylprednisolone may result in a meaningful improvement and show greater rapidity of response in cases of severe central nervous system inflammation such as arachnoiditis or myelopathy.
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http://dx.doi.org/10.5582/ddt.2021.01015DOI Listing
May 2022

Vascular anomalies: diagnostic features and step-wise approach.

Acta Radiol 2022 Mar 18:2841851221085379. Epub 2022 Mar 18.

Department of Plastic Reconstructive Surgery, 28730All India Institute of Medical Sciences, New Delhi, India.

The first part of this review article emphasized correct nomenclature, classification systems, and imaging algorithm of vascular anomalies. The second part of the review discusses the individual entities, highlighting the characteristic clinico-radiological features of the commonly encountered ones. A step-wise algorithmic approach is also proposed for the evaluation of a suspected case of vascular anomaly.
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http://dx.doi.org/10.1177/02841851221085379DOI Listing
March 2022

CT findings in renovascular injuries following abdominal trauma: a pictorial review.

Emerg Radiol 2022 Jun 5;29(3):595-604. Epub 2022 Feb 5.

Division of Trauma Surgery and Critical Care, Jai Prakash Narayana Apex Trauma Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India.

Renal vascular injuries are more devastating than parenchymal injuries alone, thus account for higher injury grade and require prompt recognition. Revised AAST organ injury scale (OIS) for renal trauma has incorporated CT-diagnosed vascular injuries into renal injury grading which includes pseudoaneurysm and arteriovenous fistula, along with addition of some new descriptors of renovascular injury. Dual-phase contrast-enhanced CT (with both arterial and venous phase) can easily pick up renovascular injuries and is the modality of choice for imaging renovascular trauma. Radiologist should be well versed with the imaging findings of renovascular injuries so that accurate injury grading can be done and further management can be planned at the earliest.
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http://dx.doi.org/10.1007/s10140-022-02027-3DOI Listing
June 2022

Post-mortem MRI in stillbirth: Normal imaging appearances.

Eur J Radiol 2022 Mar 19;148:110166. Epub 2022 Jan 19.

Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India. Electronic address:

Post-mortem MRI (PMMRI) can reliably detect most major organ malformations in cases of stillbirth. However, variable normal post-mortem changes mimicking pathology make the interpretation difficult. Varying morphological appearances of internal organs could be due to differences in gestational age of the fetuses being evaluated or the presence of maceration changes which occur after fetal demise in-utero. Final differentiation and detection of abnormality require a close interaction and inputs from the geneticist regarding clinical examination of the fetus and thorough evaluation of intranatal imaging records. With the increasing use of PMMRI in cases of fetal demise, it is prudent for the radiologists to be aware of normal post-mortem findings to avoid misdiagnosis.
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http://dx.doi.org/10.1016/j.ejrad.2022.110166DOI Listing
March 2022

STAMBP gene mutation causing microcephaly-capillary malformation syndrome: a recognizable developmental and epileptic encephalopathy.

Epileptic Disord 2022 Jan 11. Epub 2022 Jan 11.

Division of Medical Genetics, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.1684/epd.2021.1411DOI Listing
January 2022

Diagnostic utility of point of care ultrasound in identifying cervical spine injury in emergency settings.

Australas J Ultrasound Med 2021 Nov 2;24(4):208-216. Epub 2021 Jul 2.

Department of Emergency Medicine Florida State University Sarasota USA.

Introduction: The evaluation of cervical-spine in a major trauma patient needs a bedside efficient tool to rule out cervical spine injury as the role of X-ray and Computed Tomography (CT) in this setting is limited. Point of care ultrasonography (POCUS) is being used as an adjunct during trauma resuscitation. The aim of this study was to evaluate the use of POCUS for identifying cervical spine injuries.

Methods: We recruited 84 cases with cervical spine injury based on CT scan after taking consent. POCUS was used as per the operational definition of study methods while maintaining manual in-line stabilisation. Statistical analysis was done by using STATA version 14.

Results: Normal cervical anatomy was visible through anterior approach in POCUS except for the 1 and 2 cervical vertebrae. The sensitivity and specificity of POCUS vs CT scan for vertebral body listhesis were 84.52% (95% CI of 0.65-0.95) and 89.66% (95% CI 0.78-0.96) with -value <0.0001. Sensitivity and specificity of POCUS vs CT for vertebral body fracture were 40.91% (95% CI of 0.20-0.63) and 96.77% (95% CI of 0.88-0.99) with -value <0.0001. The overall sensitivity and specificity of POCUS were 45.83% and 83.33% ( = 0.06) and excluding isolated posterior column injuries, sensitivity and specificity were 70.21% and 83.33% ( < 0.05).

Conclusion: POCUS identified injuries such as fracture and listhesis. Because of high rate of missed injuries, ultrasound at present cannot be used as a screening or diagnostic tool for decision-making in cervical spine injury.
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http://dx.doi.org/10.1002/ajum.12274DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8591273PMC
November 2021

Idiopathic brachial plexopathy after pacemaker implant.

Pacing Clin Electrophysiol 2022 04 30;45(4):574-577. Epub 2021 Dec 30.

Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India.

A middle-aged woman presented with symptomatic complete heart block and underwent an uneventful dual chamber pacemaker implantation. Three weeks post procedure, she developed left arm pain and weakness, with neurological localization to the lower trunk of left brachial plexus. Possibilities of traumatic compression by the device/leads or postoperative idiopathic brachial plexopathy were considered. After ruling out traumatic causes, she was started on oral steroids, to which she responded remarkably. This case highlights the importance of recognizing this rare cause of brachial plexopathy following pacemaker implantation, because not only does an expedited diagnosis and medical treatment lead to prompt recovery with minimal neurological deficits, but it also circumvents an unnecessary surgical re-exploration.
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http://dx.doi.org/10.1111/pace.14421DOI Listing
April 2022

Peritoneal Loose Body in a Patient With Ampullary Adenocarcinoma.

ACG Case Rep J 2021 Nov 18;8(11):e00680. Epub 2021 Nov 18.

Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.14309/crj.0000000000000680DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8604031PMC
November 2021

Cerebral Venous Sinus Thrombosis in a Child with Lesch-Nyhan Syndrome.

Neurol India 2021 Jul-Aug;69(4):1021-1023

Child Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India.

Lesch-Nyhan syndrome is a rare neurometabolic condition characterized by progressive choreoathetosis, intellectual disability, and peculiar manifestations like self-mutilation. Occasional case reports in adults have suggested an association between Lesch-Nyhan syndrome and hypercoagulability; however, no such report of either a venous or arterial stroke in children with Lesch-Nyhan Syndrome exists in literature. We present a 3-year-old boy with global developmental delay, dystonic posturing, choreoathetoid movements, and self-mutilation involving fingers and lips. He had acute worsening of sensorium, recurrent seizures, and opisthotonous posturing. A diagnosis of Lesch-Nyhan Syndrome was confirmed by extremely low hypoxanthine-guanine phosphoribosyltransferase enzyme levels. In view of an acute neurological deterioration, magnetic resonance imaging brain and magnetic resonance venogram were done that showed sagittal and left transverse venous sinus thrombosis. This case is the first case report of cerebral venous sinus thrombosis in a child with Lesch-Nyhan Syndrome. It further strengthens the association between hypercoagulability and Lesch-Nyhan syndrome.
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http://dx.doi.org/10.4103/0028-3886.325342DOI Listing
September 2021

Tumefactive demyelination in pediatrics: An unusual late neurological complication of hematopoietic stem cell transplant.

Pediatr Blood Cancer 2021 11 1;68(11):e29318. Epub 2021 Sep 1.

Division of Pediatric Oncology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India.

Immune-mediated demyelination is a rare posttransplant complication. Here, we report an 8.5-year-old boy who developed left hemiparesis, 18 months post matched sibling donor hematopoietic stem cell transplant (HSCT) for relapsed acute myeloid leukemia and was diagnosed to have tumefactive demyelination. The diagnosis was established based on clinical and radiological features. The complete resolution of the lesions with steroids further established the immune-mediated pathophysiology.
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http://dx.doi.org/10.1002/pbc.29318DOI Listing
November 2021

Acute Demyelinating Syndrome (MOG Antibody Positive) Associated With COVID-19 Infection: A Widening spectrum.

Clin Pediatr (Phila) 2021 11 3;60(13):501-503. Epub 2021 Aug 3.

Child Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.1177/00099228211037210DOI Listing
November 2021

Management of Neurocysticercosis in Children: Association of Child Neurology Consensus Guidelines.

Indian Pediatr 2021 Sep 2;58(9):871-880. Epub 2021 Aug 2.

Pediatric Neurology and Neurodevelopment, Medanta the Medicity, Gurugram, Haryana. Correspondence to: Prof Pratibha Singhi, Professor and Chief, Pediatric Neurology and Neurodevelopment, Medanta the Medicity, Gurugram, India.

Justification: Neurocysticercosis (NCC) is a significant problem in India and other developing countries; however, several aspects of this disease have no clear, practical guidelines. There is a need for pragmatic guidelines, summarizing the available evidence, and filling in the gaps in evidence with expert advice to manage children with neurocysticercosis.

Process: An expert group (16 members) and a writing group (8 members) was constituted, consisting of members with varied expertise. It included pediatric neurologists (18), neurologist (1), Neuroradiologists (4), and a parasitologist (1). The writing group divided the six topics and reviewed the literature on the topics individually to determine the clinical questions for which no clear guidance was available from the literature. The experts were then contacted and opinions were obtained online. The Delphi consensus method was adopted to arrive at a general consensus regarding various questions, with both the experts and the writing group members contributing. The final guidelines were then drafted by the writing group.

Recommendations: Diagnosis of NCC should be based on clinical history and neuroimaging. Contrast-enhanced magnetic resonance imaging of the brain is the modality of choice. For single enhancing lesion, albendazole therapy for 10-14 days is recommended, and it should be combined with praziquantel for 10-14 days for more than one ring-enhancing lesions. For persistent lesion, the same dose and duration of albendazole or concurrent administration of albendazole and praziquantel should be given. Pulse intravenous steroids should be used to reduce the acute symptomatic edema in children with cysticercal encephalitis. Carbamazepine or oxcarbazepine are best suited for seizure prophylaxis for those who present with seizures; phenytoin and levetiracetam are the other alternatives. In the case of NCC presenting with symptoms other than seizures, there appears to be no role for routine anti-seizure medication prophylaxis. For a single ring-enhancing lesion, six months of anti-seizure medication is sufficient if the lesion resolves on follow-up. Those with persistent lesions, calcification, or multiple lesions, require a longer treatment duration of at least 24 months.
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September 2021

Unidentified bright objects of spleen on arterial phase CT: mimicker of splenic vascular injury in blunt abdominal trauma.

Diagn Interv Radiol 2021 Jul;27(4):497-503

JPN Apex Trauma Centre, All India Institute of Medical Sciences, Safdarjung Enclave, New Delhi, India.

Purpose: We have described unidentified bright objects of spleen (UBOS), a hitherto undescribed entity, as hyperdense areas on arterial phase (AP) computed tomography (CT) seen in relation to splenic lacerations and are isodense to the normal parenchyma on portal venous phase with no correlate on digital subtraction angiography (DSA). UBOS mimic splenic vascular injuries like active contrast extravasation and pseudoaneurysm and need to be differentiated from them as it would have implications on patient management. We undertook this study to identify CT features of UBOS that can differentiate them from splenic vascular injuries and to calculate their diagnostic accuracy.

Methods: This retrospective study was approved by the institutional ethical committee and the need for informed consent was waived. Patients with splenic injury who had undergone dual-phase CT and DSA were included. All the lesions that were hyperdense on AP were evaluated for their outline, their relation to the adjacent/parallel margins of a laceration (margin sign), string of beads appearance, and the presence of adjacent normal parenchyma (adjacent parenchyma sign). The Hounsfield unit (HU) of the lesion and the aorta on the AP were also noted. The diagnostic accuracy of various signs for distinguishing UBOS from splenic vascular injuries was calculated using DSA as the reference standard.

Results: Of 48 patients, 5 were excluded due to suboptimal quality of the examination or a time difference of more than 6 hours between the CT and DSA. A total of 54 hyperdense lesions were detected on AP in 43 patients. These were classified as vascular injuries (pseudoaneurysm, n=11; active contrast extravasation, n=11) and UBOS (n=32) based on DSA. The margin sign, string of beads appearance, and ill-defined outline had high specificity (95%, 86%, and 82%, respectively) but low sensitivity (50%, 65%, and 63%, respectively). The adjacent parenchyma sign had a moderate sensitivity and specificity of 84% and 77%, respectively. ROC analysis showed that a difference of 50 HU between the aorta and the lesion had a high sensitivity and specificity of 88.9% and 90.6%, respectively, with an area under the curve of 0.90.

Conclusion: An attenuation difference of over 50 HU between the aorta and the lesion and the presence of normal adjacent parenchyma had the highest diagnostic accuracy, while an ill-defined outline, string of beads appearance, and margin sign had high specificity but low sensitivity for differentiating UBOS from splenic vascular injuries.
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http://dx.doi.org/10.5152/dir.2021.20278DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8289430PMC
July 2021

Bilateral Facial Palsy in Lymphomatous Meningitis.

Ann Indian Acad Neurol 2021 Jan-Feb;24(1):85-86. Epub 2020 Jul 24.

Child Neurology Division, Center of Excellence & Advanced Research on Childhood Neurodevelopmental Disorders, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.4103/aian.AIAN_514_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8061525PMC
July 2020

Yoga-An Alternative Form of Therapy in Patients with Blunt Chest Trauma: A Randomized Controlled Trial.

World J Surg 2021 07 18;45(7):2015-2026. Epub 2021 Mar 18.

Division of Trauma Surgery and Critical Care, JPN Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India.

Background: Yoga as alternative form of therapy has shown positive impact on pulmonary functions, exercise capacity, behavioral changes, and inflammation in non-trauma patients. However, the efficacy of Yoga has not been studied in chest trauma patients.

Methods: This randomized controlled trial was conducted at level-1 Trauma Centre. Isolated chest injury patients were randomized into either standard physiotherapy or Yogatherapy groups. Patients in physiotherapy group received conventional chest physiotherapy and Yogatherapy group received a set of Yogic exercises in addition to conventional chest physiotherapy. Primary outcome measure was changes in pulmonary function tests (PFT) at 4 weeks of discharge. Secondary outcomes were changes in quality of life (QoL), respiratory muscle strength and endurance, chest wall mobility, and levels of cytokines at 4 weeks. Data were analyzed using STATA v14.0.

Results: A total of 89 eligible patients were randomized to physiotherapy (n = 46) and Yoga therapy (n = 43) groups. Demographic characteristics were comparable in both the groups. There were statistically significant improvements in PFT in the Yogatherapy group compared with physiotherapy with an increase in Forced vital capacity (p = 0.02) and Forced expiratory volume (p = 0.01) at 4 weeks. In addition, there were significant improvement in physical component of QoL, respiratory muscle endurance (p = 0.003) and axillary cirtometry (p = 0.009) in the Yogatherapy group. However, no statistically significant difference in the trends of cytokine markers seen between the groups.

Conclusion: Yoga was found to be effective in improving pulmonary functions and QoL in patients with chest trauma. (Trial registered at ctri.nic.in/clinicaltrials/login.php, numberREF/2016/05/011,287).
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http://dx.doi.org/10.1007/s00268-021-06057-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7972014PMC
July 2021

Impact of clinical parameters and vascular haemodynamics on arterio-venous fistula maturation in patients with end stage renal disease: A prospective study on Indian patients.

J Vasc Access 2021 Mar 14:11297298211001158. Epub 2021 Mar 14.

Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.

Background: About 18%-65% of Arterio-Venous fistula (AVF) made to facilitate haemodialysis in end stage renal disease patient fail to mature. This study was designed to evaluate the impact of clinical parameters and vascular haemodynamics on maturation of AVF on Indian patients.

Material And Methods: This was a prospective observational study. Eligible patients' clinical profiles and vascular haemodynamics by Doppler ultrasonography were noted. All patients underwent radio-cephalic AVF on the non-dominant arm under local anaesthesia. Clinical definition was used to assess success rate of AVFs which is defined as successful six settings of satisfactory dialysis. Data were analysed using Stata/12.0 software. Independent -test, chi-square test, logistic regression analysis and multivariate analysis were used. The -value of <0.05 was considered significant.

Results: A total of 205 patients were enrolled and analysed. Among clinical factors, age, sex, serum creatinine, hypertension had no significant association with failure (p = 0.5, 0.08, 0.76 and 0.74). Patient's BMI and presence of diabetes had significant impact on outcome ( < 0.001 and 0.02 respectively). Among vascular haemodynamics, radial vein diameter of >2.5 mm and radial artery flow rate >40 ml/min had no significant association with failure ( = 0.12 and 0.28). Diameter of radial artery (>2 mm) and intra-operatively immediate thrill were independent predictor of success (p = 0.002 and <0.001).

Conclusion: In the present study rate of fistula, maturation was 73.2% without any post-operative radiological intervention. Radial artery diameter >2 mm and presence of immediate thrill post-operatively were significantly associated with successful cannulation.
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http://dx.doi.org/10.1177/11297298211001158DOI Listing
March 2021

Exocrine and endocrine functions and pancreatic volume in patients with pancreatic trauma.

Eur J Trauma Emerg Surg 2022 Feb 14;48(1):97-105. Epub 2021 Mar 14.

Division of Trauma Surgery and Critical Care, Department of Surgical Disciplines, JPN Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, 29, India.

Introduction: Injury to the pancreas may lead to significant morbidity and mortality. We aim to assess pancreatic endocrine and exocrine functions and evaluated morphological regenerations of pancreas following partial pancreatectomy in patients with pancreatic trauma.

Methods: The study was performed between June 2016 and December 2017. Endocrine functions were assessed at the time of admission and at 6 months follow-up with 75 g oral glucose tolerance test (OGTT), serum insulin and C-peptide levels and HbA1c estimation and exocrine functions were assessed with fecal elastase test. Pancreatic volumetry was done with imaging scan at 1 month and 6 months post discharge.

Results: Twenty patients were studied with a median age of 30 years (range18-48) at the time of injury. All the patients were normoglycemic on admission; only one patient who underwent pancreatic resection developed diabetes mellitus at follow-up. Eight patients (40%) were found to be prediabetic by American Diabetes Association (ADA) criteria. Eleven patients (55%) had pancreatic exocrine insufficiency. Pancreatic volume increment, from the mean pancreatic volume of 48.65 to 54.29 cm, was noted in patients who underwent partial pancreatectomy.

Conclusions: Patients with pancreatic trauma may develop biochemical endocrine and exocrine insufficiencies following pancreatic resection. Pancreatic volume increment requires further research in a larger study.
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http://dx.doi.org/10.1007/s00068-021-01638-8DOI Listing
February 2022

Neurocognitive Outcomes and Their Diffusion Tensor Imaging Correlates in Children With Mild Traumatic Brain Injury.

J Child Neurol 2021 07 24;36(8):664-672. Epub 2021 Feb 24.

Child Neurology Division, Center of Excellence & Advanced Research on Childhood Neurodevelopmental Disorders, Department of Pediatrics, 29751All India Institute of Medical Sciences, New Delhi, India.

This study aimed to assess the neurocognitive outcomes and their diffusion tensor imaging correlates in children (aged 6-16 years) with mild traumatic brain injury. This prospective analysis included 74 children with mild traumatic brain injury (52 boys; mean age: 9.5 [±2.7] years). Wechsler Intelligence Scale for Children-Indian adaptation (WISC-IV), Child Behavior Checklist, and Children's Sleep Habits Questionnaire were administered for 57 cases (at 3 months postinjury) and 51 controls of similar age. The findings of diffusion tensor imaging (done within 7 days of injury) were correlated with various WISC-IV indices. The presenting features at the time of injury were loss of consciousness (53%), confusion or disorientation (47%), and post-traumatic amnesia (10%). Other features in the acute phase included drowsiness (86%), headache (78%), balance problems (62%), nausea (47%), fatigue (45%), vomiting (35%), nasal or ear bleed (12%), sensitivity to sound and light (12%), etc. At 3 months postinjury, the children with mild traumatic brain injury performed poorly in terms of Intelligence Quotient, perceptual reasoning index, and processing speed index as compared to controls. Based on the Child Behavior Checklist, 17% of children with mild traumatic brain injury had internalizing behavioral problems in comparison with 4% of controls. Prevalence of poor sleepers in the mild traumatic brain injury cohort and controls was 12.3% and 2% respectively. Headache, reduced attention span, and fatigue were common postconcussion symptoms. There was a positive correlation between right uncinate fasciculus fractional anisotropy and verbal comprehension index ( = 0.32; < .05).
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http://dx.doi.org/10.1177/0883073821996095DOI Listing
July 2021

Traumatic Arterio-Enteric Fistula-A Report of 2 Cases With Review of Literature.

Vasc Endovascular Surg 2021 Aug 24;55(6):631-637. Epub 2021 Feb 24.

Division of Trauma Surgery and Critical Care, Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, Delhi, India.

Background: Traumatic arterio-enteric fistula is predominantly seen after penetrating trauma with only 21 reported cases documented in the past 25 years. They may present in an acute or delayed manner with upper or lower gastrointestinal bleed. A detailed clinical examination with requisite imaging can help in detecting such injuries.

Case Description: Case 1: A 20-year-old gentleman, presented with penetrating stab injury to the gluteal region with bleeding per rectum. Imaging revealed evidence of injury to the inferior rectal artery which was found to be communicating with the extraperitoneal portion of the rectum. He was managed with a combination of endovascular and open surgery with a successful outcome. Case 2: A 29-year-old gentleman, presented in a delayed manner 2 weeks after a gunshot wound to the gluteal region, which was managed operatively in another hospital. He developed a massive lower gastrointestinal bleed 2 weeks after presentation. Imaging revealed evidence of a pseudoaneurysm of the inferior gluteal artery which had a fistulous communication with the gastrointestinal tract leading to bleeding. It was managed by endovascular techniques successfully.

Conclusion: Arterio-enteric fistulas following trauma are rare phenomena and they need a high index of suspicion for diagnosis. Once diagnosed, they can be managed based on their location and patient physiology by interventional techniques, surgery, or a combination of the two.
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http://dx.doi.org/10.1177/1538574421994413DOI Listing
August 2021

Orbital Apex Syndrome: A Clinico-anatomical Diagnosis.

J Pediatr Neurosci 2020 Jul-Sep;15(3):336-337. Epub 2020 Nov 6.

Division of Child Neurology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India.

An 8-month-old girl presented with fever, restricted left eye movements and increasing proptosis for 8 days. On examination she had left orbital cellulitis, relative afferent pupillary defect and ophthalmoplegia. Contrast-enhanced magnetic resonance imaging (MRI) brain with orbits revealed orbital apex syndrome (OAS) with cavernous sinus thrombosis. Orbital apex is located posteriorly in the orbit and characterised by involvement of cranial nerves II, III, IV, VI and ophthalmic division of Vth nerve. The close clinico-anatomical differentials of OAS are cavernous sinus and superior orbital fissure syndrome. The current case was treated successfully with intravenous antibiotics and anticoagulation therapy.
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http://dx.doi.org/10.4103/jpn.JPN_114_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7847102PMC
November 2020

Artificial Intelligence-assisted chest X-ray assessment scheme for COVID-19.

Eur Radiol 2021 Aug 20;31(8):6039-6048. Epub 2021 Jan 20.

Indian Institute of Technology, Delhi, New Delhi, India.

Objectives: To study whether a trained convolutional neural network (CNN) can be of assistance to radiologists in differentiating Coronavirus disease (COVID)-positive from COVID-negative patients using chest X-ray (CXR) through an ambispective clinical study. To identify subgroups of patients where artificial intelligence (AI) can be of particular value and analyse what imaging features may have contributed to the performance of AI by means of visualisation techniques.

Methods: CXR of 487 patients were classified into [4] categories-normal, classical COVID, indeterminate, and non-COVID by consensus opinion of 2 radiologists. CXR which were classified as "normal" and "indeterminate" were then subjected to analysis by AI, and final categorisation provided as guided by prediction of the network. Precision and recall of the radiologist alone and radiologist assisted by AI were calculated in comparison to reverse transcriptase-polymerase chain reaction (RT-PCR) as the gold standard. Attention maps of the CNN were analysed to understand regions in the CXR important to the AI algorithm in making a prediction.

Results: The precision of radiologists improved from 65.9 to 81.9% and recall improved from 17.5 to 71.75 when assistance with AI was provided. AI showed 92% accuracy in classifying "normal" CXR into COVID or non-COVID. Analysis of attention maps revealed attention on the cardiac shadow in these "normal" radiographs.

Conclusion: This study shows how deployment of an AI algorithm can complement a human expert in the determination of COVID status. Analysis of the detected features suggests possible subtle cardiac changes, laying ground for further investigative studies into possible cardiac changes.

Key Points: • Through an ambispective clinical study, we show how assistance with an AI algorithm can improve recall (sensitivity) and precision (positive predictive value) of radiologists in assessing CXR for possible COVID in comparison to RT-PCR. • We show that AI achieves the best results in images classified as "normal" by radiologists. We conjecture that possible subtle cardiac in the CXR, imperceptible to the human eye, may have contributed to this prediction. • The reported results may pave the way for a human computer collaboration whereby the expert with some help from the AI algorithm achieves higher accuracy in predicting COVID status on CXR than previously thought possible when considering either alone.
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http://dx.doi.org/10.1007/s00330-020-07628-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7816060PMC
August 2021

Utility of admission perfusion CT for the prediction of suboptimal outcome following uncomplicated minor traumatic brain injury.

Emerg Radiol 2021 Jun 9;28(3):541-548. Epub 2021 Jan 9.

Department of Radiodiagnosis, All India Institute of Medical Sciences, Room no. 81b, 110029, New Delhi, India.

Purpose: To compare the perfusion parameters of patients with uncomplicated mild traumatic brain injury (mTBI) with healthy controls and to assess whether admission perfusion CT parameters can be used to predict outcome at 6 months post-injury in patients with uncomplicated mTBI.

Methods: Institute ethical committee approval was obtained for this prospective cohort study and informed written consent obtained from all subjects. Patients who sustained mTBI and had no abnormalities on non-contrast CT from June 2010 to January 2012 (20 months) and 10 healthy controls were included and underwent perfusion CT at admission. Outcome was determined at 6 months follow-up using the extended Glasgow Coma Outcome Scale score.

Results: Forty-nine patients were included, of which 16 (32.7%) had symptoms at 6 months post-injury (suboptimal outcome). The mean cerebral blood flow and volume were lower in both the gray and white matter of all three arterial territories in the study group than in the control group (p value < 0.05). In the study group, these values were lower in those with suboptimal outcome than in those with optimal outcome (no symptoms). Cerebral blood flow showed higher area under the curve for predicting the outcome.

Conclusion: Perfusion parameters are altered even in patients with uncomplicated mTBI. A single ROI (region of interest) evaluation of the gray matter in the posterior cerebral artery territory on admission perfusion CT could provide a quick and efficient way to predict patients who would have a suboptimal outcome at 6 months post-injury.
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http://dx.doi.org/10.1007/s10140-020-01876-0DOI Listing
June 2021

Kimura Disease: A Case Series and Systematic Review of Clinico-radiological Features.

Curr Probl Diagn Radiol 2022 Jan-Feb;51(1):130-142. Epub 2020 Nov 17.

Department of Plastic and Reconstructive Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India.

Kimura disease is a rare chronic inflammatory disorder mostly reported in males in second to third decades from south-east Asia. Head and neck is the most commonly involved region. The usual presentation is painless facial swelling with salivary gland involvement and regional lymphadenopathy. The diagnosis can be suspected on imaging but needs to be proven on histopathology. We describe three histopathology proven cases of Kimura disease and emphasize the specific clinic-radiological findings which can help in early identification of the condition and its differentiation from other diseases with similar presentation. Gray scale Ultrasound, contrast-enhanced ultrasound, and contrast-enhanced Magnetic Resonance Imaging (CE-MRI) were done in all patients and Computed Tomography (CT) was done in one. The salient imaging features were ill-defined solid mass in the subcutaneous location of the facial region which was heteroechoic on Gray scale Ultrasound, heterogeneously hyperintense on T2W MRI and without much diffusion restriction. There was involvement of salivary glands with ipsilateral cervical adenopathy. The lesion showed avid contrast enhancement on contrast-enhanced ultrasound and CE-MRI. We also present a systematic literature review of clinico-radiological features in Kimura disease in the head and neck. The articles with histopathologically proven cases and satisfactory description of imaging findings were included and we have compared the findings in our cases with published literature. In addition, we have included examples of radiological mimics of this disease. Certain imaging findings are highly suggestive and can aid in early diagnosis of Kimura disease which helps in early initiation of treatment with better patient prognosis.
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http://dx.doi.org/10.1067/j.cpradiol.2020.10.003DOI Listing
December 2021

Development of a novel outcome prediction score (PEDSS) for pediatric convulsive status epilepticus: A longitudinal observational study.

Epilepsia 2020 12 13;61(12):2763-2773. Epub 2020 Nov 13.

Center of Excellence and Advanced Research on Childhood Neurodevelopmental Disorders, Child Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India.

Objective: The objectives of this study were to evaluate ENDIT score and develop a novel outcome prediction score for outcome of pediatric convulsive status epilepticus (CSE) at the hospital and 3 months postdischarge.

Methods: Children and adolescents aged 1 month to 14 years, presenting with CSE to a tertiary care teaching center in North India from January 2017 to March 2019, were screened for enrollment. In-hospital and 3-month postdischarge outcome were defined as poor if Pediatric Cerebral Performance Category Scale (PCPCS) score dropped by ≥2 levels.

Results: Overall, 61 patients were enrolled for final analysis after applying exclusion and inclusion criteria. The area under the receiver operating characteristic (ROC) curve for ENDIT score in predicting mortality and differentiating good from poor outcome at the hospital and at 3 months postdischarge was 0.74 (95% confidence interval [CI] = 0.58-0.89), 0.7 (95% CI = 0.57-0.83), and 0.72 (95% CI = 0.6-0.82), respectively. Based on predictors in the present cohort that were significantly different between good and poor outcome cases at the hospital and 3 months postdischarge, a new six-point score named PEDSS (pre-status epilepticus PCPCS, background electroencephalographic abnormalities, drug refractoriness, semiology, and critical sickness) was developed. The area under ROC curves for PEDSS score in predicting mortality and differentiating good from poor outcome at the hospital and at 3 months postdischarge were 0.93 (95% CI = 0.87-0.99), 0.8 (95% CI = 0.7-0.9), and 0.89 (95% CI = 0.8-0.96), respectively. The best cutoff PEDSS scores for predicting mortality and poor outcome at the hospital and at 3 months postdischarge were ≥4, ≥3, and ≥3, respectively.

Significance: The PEDSS score has high predictive accuracy for mortality and differentiating good from poor outcome at the hospital and 3 months postdischarge in pediatric CSE. Future studies should be planned to validate it in various geographical and health care settings and in adults.
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http://dx.doi.org/10.1111/epi.16747DOI Listing
December 2020

Evaluation of the Graft Kidney in the Early Postoperative Period: Performance of Contrast-Enhanced Ultrasound and Additional Ultrasound Parameters.

J Ultrasound Med 2021 Sep 12;40(9):1771-1783. Epub 2020 Nov 12.

Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.

Objectives: To evaluate the various quantitative parameters of Doppler ultrasound, contrast-enhanced ultrasound (CEUS), and shear wave elastography (SWE) of graft kidneys in the early postoperative period and to explore their utility in the diagnosis of parenchymal causes of graft dysfunction.

Methods: In this ethically approved study, consecutive patients who underwent renal transplantation from March 2017 to August 2018 were recruited, and those with urologic or vascular complications and those who denied consent were excluded. All patients underwent ultrasound with Doppler, SWE, CEUS (using sulfur hexafluoride), and renal scintigraphic examinations 3 to 10 days after transplantation. A composite reference standard was used, including the clinical course, renal function test results, urine output, and histopathologic results for graft dysfunction. Cortical SWE values, quantitative CEUS parameters (generated from a time-intensity curve), and their ratios were analyzed to identify graft dysfunction and differentiate acute tubular necrosis (ATN) from acute rejection (AR).

Results: Of the 105 patients included, 19 developed graft dysfunction (18.1%; 12 ATN, 5 AR, and 2 drug toxicity) in the early postoperative period. The peak systolic velocity in the interpolar artery showed a significant difference between control and graft dysfunction groups (P < .001) as well as between ATN and AR (P = .019). Resistive indices and SWE did not show significant differences. Ratios of the time to peak showed a significant difference between control and graft dysfunction groups (P < .05). The rise time and fall time of the large subcapsular region of interest and the rise time ratio were significantly different between ATN and AR (P = .03).

Conclusions: Contrast-enhanced ultrasound can be used to diagnose parenchymal causes of early graft dysfunction with reasonable diagnostic accuracy.
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http://dx.doi.org/10.1002/jum.15557DOI Listing
September 2021

Electrographic pattern recognition: A simple tool to predict clinical outcome in children with lissencephaly.

Seizure 2020 Dec 31;83:175-180. Epub 2020 Oct 31.

Center of Excellence and Advanced Research on Childhood Neurodevelopmental Disorders, Child Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India. Electronic address:

Purpose: To describe and correlate the clinical, radiological and EEG findings in children with lissencephaly.

Method: Retrospective record analysis of children with lissencephaly presenting to tertiary health centre in Northern India was performed. Radiological classification and severity scoring were done. EEG findings were categorized into three patterns and its association with clinical severity was studied.

Results: Twenty-eight children (males = 17) with lissencephaly were enrolled. Median age at diagnosis was 6.5months (range 3days-3years). Global developmental delay (median social quotient (SQ) = 25 (range15-68) was seen in all; motor deficits in 23 (82 %); epilepsy in 21 (75 %); behavioural problems in 18 (64 %); ophthalmic problems in 17 (61 %); microcephaly in 13 (46 %); feeding difficulty in 12 (43 %). Radiologically, classical Type I lissencephaly was seen in 18(64 %), cobblestone variant (Type II) in 5 (18 %) and microlissencephaly in 5 (18 %). Grade 4 (diffuse pachygyria) radiologic severity was most common (severity grade 1-6); no cases with severity score 5 or 6 were seen. The clinical profile did not correspond with radiological severity grading. EEG pattern recognition revealed pattern I in 14 (50 %); pattern II in 6 (21 %); pattern III in 8 (29 %). Children with pattern III EEG had drug resistant epilepsy and severe developmental delay. No relationship between EEG patterns and radiological severity grading was evident.

Conclusion: EEG is better predictor of clinical status and outcome rather than radiological severity grading. EEG pattern III is associated with severe developmental delay and drug resistant epilepsy.
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http://dx.doi.org/10.1016/j.seizure.2020.10.020DOI Listing
December 2020

Mutation Spectrum of Tuberous Sclerosis Complex Patients in Indian Population.

J Pediatr Genet 2021 Dec 7;10(4):274-283. Epub 2020 Sep 7.

Department of Pediatrics, Division of Genetics, All India Institute of Medical Sciences, New Delhi, India.

Tuberous sclerosis complex (TSC) is a multiorgan disorder characterized by formation of hamartomas and broad phenotypic spectrum including seizures, mental retardation, renal dysfunction, skin manifestations and brain tubers. It is inherited in an autosomal dominant pattern, caused due to mutation in either or genes. Seizures are one of the major presenting symptoms of TSC that helps in early diagnosis. The present study describes the mutation spectrum in and genes in TSC patients and their association with neurocognitive-behavioral phenotypes. Ninety-eight TSC patients were enrolled for TSC genetic testing after detailed clinical and neurobehavioral assessment. Large genomic rearrangement testing was performed by multiplex ligation-dependent probe amplification (MLPA) technique for all cases and Sanger sequencing was performed for MLPA negative cases. Large rearrangements were identified in approximately 1% in and 14.3% in genes. The present study observed the presence of duplications in two (2%) cases, both involving contiguous genes which to the best of our knowledge is reported for the first time. 8.1% of small variants were identified in the gene and 85.7% in gene, out of which 23 were novel variations and no variants were found in six (6.1%) cases. This study provides a representative picture of the distribution of variants in the and genes in Indian population along with the detailed assessment of neurological symptoms. This is the largest cohort study from India providing an overview of comprehensive clinical and molecular spectrum.
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http://dx.doi.org/10.1055/s-0040-1716495DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8608467PMC
December 2021
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