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YENEPOYA MEDICAL COLLEGE,

YENEPOYA UNIVERSITY,
MANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS


FOR DISSERTATION

Dr. Manu Joseph

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PART A: PERSONAL DETAILS

1.Name of the Student

2.Campus ID

DR. MANU JOSEPH


5900

3.Name of the Department and


College

DEPARTMENT OF RADIODIAGNOSIS
YENEPOYA MEDICAL COLLEGE,
DERALAKATTE, MANGALORE.

4.Name of the Postgraduate


Course

M.D. RADIODIAGNOSIS

5.Date of admission to course

6.Contact details

Dr. Manu Joseph

30/05/2015
drmanujoseph90@gmail.
com
9686466721

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7.Name of the PG Guide

DR.DEVDAS ACHARYA

PART B: PROJECT DETAILS


1.Title of Research Proposal
ANATOMIC VARIATIONS IN THE DURAL VENOUS ANATOMY WITH MR VENOGRAPHY-AN
EXPLORATORY STUDY

2.Introduction

Knowledge of variations in the cerebral venous anatomy andapparent signal


abnormalities seen on Magnetic resonance (MR) angiography are essential to avoid overdiagnosis of cerebral venous sinus thrombosis (CVST), while
interpreting the MR angiograms..Magnetic resonance (MR) angiography is one of the
accepted methods of evaluation of the cerebral venous sinus anatomy as well as
pathology.[1,2] Among others, the CT venography and conventional angiography are
notable methods. The disadvantages of the conventional angiography are the use of
ionizing radiation and the invasiveness of the procedure with its inherent complications.
The CT Venography also involves high radiation dose. However, the use of MR
angiography has got several advantages compared to other methods. In the MR
angiography, there is a possibility of acquiring images with or without the use of contrast
media. Techniques used to perform the MR angiography without the injection of
gadolinium chelete are, the time-of-flight (TOF) and phase-contrast (PC) angiography.
Two dimensional (2D) and three dimensional (3D) acquisitions can be used in either of
these techniques. There are many pitfalls in the diagnosis of the cerebral venous sinus
thrombosis (CVST) on MR angiography. The study aims to evaluate the normal MR
appearances of cerebral venous sinus
anatomy and its variations, as well as the apparent MR signal abnormalities seen
normally, in the MR angiography done using a 0.5 Tesla MR equipment.

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3.Review of literature

1.Cerebral MR Venography: Normal Anatomy and


Potential Diagnostic Pitfalls
R. H. Ayanzen, C. R. Bird, P. J. Keller, F. J. McCully, M. R. Theobald, and J. E. Heiserman

BACKGROUND AND PURPOSE: MR

venography is often used to examine the intracranial


venous system, particularly in the evaluation of dural sinus thrombosis. The purpose of
this
study was to evaluate the use of MR venography in the depiction of the normal
intracranial
venous anatomy and its variants, to assess its potential pitfalls in the diagnosis of dural
venous
sinus thrombosis, and to compare the findings with those of conventional catheter
angiography.
METHODS: Cerebral MR venograms obtained in 100 persons with normal MR imaging
studies were reviewed to determine the presence or absence of the dural sinuses and
major
intracranial veins.
RESULTS: Systematic review of the 100 cases revealed transverse sinus flow gaps in 31%
of
the cases, with 90% of these occurring in the nondominant transverse sinus and 10% in
the
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codominant transverse sinuses. No flow gaps occurred in the dominant transverse


sinuses. The
superior sagittal and straight sinuses were seen in every venogram; the occipital sinus
was seen
in only 10%. The vein of Galen and internal cerebral veins were also seen in every case;
the
basal veins of Rosenthal were present in 91%.
CONCLUSIONS: Transverse sinus flow gaps can be observed in as many as 31% of patients
with normal MR imaging findings; these gaps should not be mistaken for dural sinus
thrombosis.
2.VARIATIONS IN THE CEREBRAL VENOUS ANATOMY AND PITFALLS

IN THE DIAGNOSIS OF CEREBRAL VENOUS SINUS THROMBOSIS:


LOW FIELD MR EXPERIENCE
N. R. S. SURENDRABABU, SUBATHIRA, R. S. LIVINGSTONE

ABSTRACT

Knowledge of variations in the cerebral venous anatomy and


apparent signal abnormalities seen on Magnetic resonance (MR) angiography are
essential to avoid over-diagnosis of cerebral venous sinus thrombosis (CVST), while
interpreting the MR angiograms. AIMS: To evaluate the variations of cerebral venous
anatomy and signal abnormalities by using 3D phase contrast MR angiography
performed in a 0.5 Tesla MRI scanner. MATERIALS AND METHODS: One hundred
patients who underwent MR imaging and MR angiography examinations at our
institution from March 2004 to February 2005, with normal MR imaging of brain were
studied retrospectively. Patients with clinical suspicion of CVST and patients who
underwent color doppler evaluation for suspected deep vein thrombosis were excluded.
RESULTS: The superior sagittal, straight sinus and the internal cerebral veins were
visualized in all patients. There was hypoplasia of the right transverse sinus in 13
patients, left transverse sinus in 35 patients, right sigmoid sinus in 6 patients and left
sigmoid sinus in 19 patients. Absence of transverse sinus on left side was observed in
one patient and absence of sigmoid sinus in 2 patients on left side. Flow gaps were
observed in non-dominant transverse sinus, sigmoid sinus as well as transverse sigmoid
sinus junctions. The occipital sinus was visualized in 17 patients. CONCLUSIONS:
MR angiography done at low field strengths is also a reliable method, for assessing
cerebral venous sinuses. Awareness of the normal anatomical variations of venous
sinuses and apparent MR angiographic flow gaps prevent misdiagnosis of cerebral
venous sinus thrombosis.
BACKGROUND:

Intracranial MR Venography in Children:


Normal Anatomy and Variations
3.

E. Widjaja and P.D. Griffiths

BACKGROUND AND PURPOSE:

Little information is available regarding the anatomy of

the
intracranial veins and sinuses that can be shown on MR venograms of children. The aim
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of this
study was to determine the normal venous anatomy and anatomic variants.
METHODS: Fifty children who were referred for investigation of developmental delay
and
who had normal results of MR imaging of the brain were recruited into the study. The
cerebral
veins and sinuses, including the occipital sinuses, were assessed by using 2D time-offlight
venography. Particular attention was paid to the anatomy of the venous confluence.
RESULTS: Twenty-seven cases had dominant right transverse sinuses, 18 had dominant
left
transverse sinuses, four had co-dominant transverse sinuses, and one had absence of both
transverse
sinuses. In 21 (51%) of 41 cases without occipital sinuses, absent or hypoplastic
transverse
sinuses were found. Nine patients had occipital sinuses. Five (56%) of nine patients with
occipital
sinuses were younger than 2 years, and patients younger than 2 years accounted for 24%
of all
patients (12 of 50 patients) in the study. In six (67%) of nine patients with occipital
sinuses, absent
or hypoplastic transverse sinuses were shown. Two patients had bulbous prominence of
the vein of
Galen. One had foreshortened superior sagittal sinus, which in turn is drained by two
paramedian
cortical veins.
CONCLUSION: Understanding the normal anatomy of the cerebral venous system and its
variants by using MR venography in children provided the background to future studies
on
anomalous venous structure in malformations of the brain.

Dural Sinus Thrombosis: Sources of


Error in Image Interpretation
4.

James M. Provenzale1,2
Peter G. Kranz1
OBJECTIVE.

The purpose of this article is to bring some of the potential causes of false-

positive and false-negative interpretations of dural sinus thrombosis (DST) on


cross-section imaging studies to the attention of radiologists.
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The prompt diagnosis of DST can be important in many cases and a


false-positive diagnosis can cause a delay in establishing the correct diagnosis as well as
lead
to implementation of inappropriate therapy. We hope that this article helps to reduce the
number
of such cases in the daily practice of the reader.
CONCLUSION.

1.Hypothesis
2.Aim and Objectives of the study
to evaluate the use of MR venography in the depiction of the normal intracranial
venous anatomy and its variants
To bring some of the potential causes of falsepositive
and false-negative interpretations of dural sinus thrombosis (DST) on cross-section
imaging studies to the attention of radiologists.

3.Methodology
To evaluate the variations of cerebral venousanatomy and signal abnormalities by using
3D phase contrast MR angiography
performed in a 0.5 Tesla MRI scanner.
4. Study design
Prospective compartive study

5. Materials and Methods


After ethical committee approval and informed consent, patients belonging to either
sex , aged between to years,
MR examinations were performed
using a 0.5T MR equipment (Philips
Gyroscan T5-NT, Netherlands) in our
institution where the study was conducted.
The MR angiographic examinations were
performed using the 3D phase contrast
technique without applying the inferior
saturation band. The slice thickness of 1.2
mm was acquired with contiguous sections
using matrix size of 256 x 256 and a nominal
field of view (FOV) of 27 cm with TR (Time
to Repeat) -22 milliseconds, TE (Time to
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Echo) -7.4 milliseconds and flip angle of 15o.


The velocity encoding applied was 30-40 cm
per second. The images were displayed as
20 maximum intensity projection (MIP)
images reconstructed from the source images
at 9 degree increments.
Patients who underwent MR imaging at our
institution were selected from picture
archiving and communication system (PACS)
database, from March 2004 to February 2005.
One hundred patients were selected by
viewing the normal MR imaging of the brain,
who also had MR angiographic examination.
The age of patients included was between 2
to 68 years with a median age of 35 years.
These patients MR angiograms were
systematically reviewed in the PACS
(General Electric, Milwaukee, USA)
workstation using high resolution monitors.
The dural venous sinuses included in this
study are superior sagittal sinus, sigmoid
sinus, transverse sinus, straight sinus and
occipital sinus. Other major cerebral veins
which were relatively constant and included
in the study were internal cerebral veins,
superficial cortical veins i.e, veins of Trolard
and Labbe. The clinical indication of the
headache was also included in the study as
it was a general symptom for which clinicians
would require cross sectional imaging in order
to rule out any other intracranial
abnormalities. Twenty six patients with this
indication were included in our study with
normal MR imaging. All these twenty six
patients were followed up clinically for a
period of 6 months, who had treated with antimigraine
therapy and all of them improved
with this therapy. Patients with ischemic
changes, lacunar infarcts, tumors, myelination
disorders, small vessel disease and other
congenital and acquired morphological
abnormalities were excluded from the study.
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Patients with clinical indication of cerebral


venous sinus thrombosis (CVST) and clinical
suspicion of deep vein thrombosis (DVT) with
color doppler imaging were also excluded from
the study.
The transverse sinuses were measured 1 cm
from the Torcula heterophili and the sigmoid
sinuses were measured 1 cm from the
transverse sigmoid junctions. These were
compared with the superior sagittal sinus. If
the linear measurement was less than half the
size of the superior sagittal sinus, it was
considered hypoplastic and if not visualised
it was considered aplastic or absence of
sinus. The internal jugular veins were not
included in the study. The dominance of
sinuses and variations in drainage of the
superior sagittal sinus and straight sinus as
well as flow gaps in these sinuses were
studied.

6.3 Source of the data/ Sampling method


Patients in Yenepoya Medical College Hospital, Mangalore who are admitted during
the period from october 2015 to October 2017 being
6.4Sample Size
Total patients

6. Inclusion Criteria
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Patients who underwent MR imaging at our


institution were selected
The age of patients included was between 2
to 68 years with a median age of 35 years.
The dural venous sinuses included in this
study are superior sagittal sinus, sigmoid
sinus, transverse sinus, straight sinus and
occipital sinus. Other major cerebral veins
which were relatively constant and included
in the study were internal cerebral veins,
superficial cortical veins i.e, veins of Trolard
and Labbe. The clinical indication of the
headache was also included in the study as
it was a general symptom for which clinicians
would require cross sectional imaging in order
to rule out any other intracranial abnormalities.

6.6 Exclusion Criteria


Patients with ischemic
changes, lacunar infarcts, tumors, myelination
disorders, small vessel disease and other
congenital and acquired morphological
abnormalities were excluded from the study.
Patients with clinical indication of cerebral
venous sinus thrombosis (CVST) and clinical
suspicion of deep vein thrombosis (DVT) with
color doppler imaging were also excluded from
the study.
7 Statistical analysis
The data will be analyzed using repeated anova and independent t test.

1.Work plan
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This study will be conducted in the Department of Radiodiagnosis at Yenepoya

Medical College Hospital over a period from October 2015 to October 2017
After the ethical committee clearance the work will be started.

Zero to twenty months


Patient will be selected according to Criteria
Written informed consent will be taken from all patients.

Data collection

Twenty to twenty four months


Statistical analysis.
Result interpretation.

Final dissertation submission.

8. Ethical Issues
8.1 Investigation / intervention needs patients or human subjects/materials
Yes, patients consent form, clinical data proforma enclosed
8.2 Does the study needs animals or materials from animals?
No
8.3 Questionnaire Study:
Not applicable

9. Biosafety Issues:
Not applicable

10 .Utilization of Results of the research and specific deliverables :


Publications in journals.

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Conference presentation.
Intervention studies can be planned in future.

11. References

Dr. Manu Joseph

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PARTC:
Table of Contents

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Signature of the student -------------------------------------------------------------

Recommendation of the PG teacher/guide---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Signature of the PG teacher/Guide------------------------------------------------Name and designation- DR. DEVDAS ACHARYA


H.O.D
DEPARTMENT OF RADIODIAGNOSIS

Signature of the Head of the Department------------------------------------------

Signature of the Principal/Dean-----------------------------------------------------

INFORMED CONSENT FORM


Dr. Manu Joseph

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TOPIC: ANATOMIC

VARIATIONS IN THE DURAL VENOUS ANATOMY WITH MR


VENOGRAPHY-AN EXPLORATORY STUDY

I . Declare that I have been briefed and hereby consent to


be included as a subject in the following dissertation ANATOMIC VARIATIONS IN THE DURAL
VENOUS ANATOMY WITH MR VENOGRAPHY-AN EXPLORATORY STUDY . I have been

informed to my satisfaction by the attending doctor, DR.MANU JOSEPH the procedure and the
complications arising from it, she has also explained to me about any untoward incidents during
the procedure and I believe that care shall be taken to avoid any such complications by the doctor
and staff. I have been explained that my decision to take part in the study shall not affect my
treatment. This has been explained to me in my language and I give consent for the same. I give
my consent for the publication of the data without revealing my identity. In case I have any
questions or queries, I have been asked to contact Dr.Manu Joseph whose number has been
mentioned below.

SIGNATURE OF DOCTOR
NAME OF DOCTOR
Dr. MANU JOSEPH
9686466721

SIGNATURE OF PATIENT/RELATIVE
NAME OF PATIENT/RELATIVE

WITNESS
RELATIONSHIP
DATE

PROFORMA

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DISSERTATION STUDY
ANATOMIC VARIATIONS IN THE DURAL VENOUS ANATOMY WITH MR
VENOGRAPHY-AN EXPLORATORY STUDY

NAME OF THE PATIENT:


AGE:

SEX:

IP NUMBER:

DATE:

GROUP:

STUDY NUMBER:

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From,
Dr. MANU JOSEPH
st
Postgraduate student (1 year),
Department of Radiodiagnosis,
Yenepoya Medical College Hospital.
To,
The Secretary,
Institution Ethics Committee,
Yenepoya Medical College.
Respected Sir/Madam,
Subject: Regarding ethical clearance for my thesis
I Dr.Manu Joseph will be doing dissertation work as part of my postgraduate course in M.D
RADIODIAGNOSIS, the topic being ANATOMIC VARIATIONS IN THE DURAL VENOUS
ANATOMY WITH MR VENOGRAPHY-AN EXPLORATORY STUDY under the guidance of

Professor DR.DEVDAS ACHARYA. In this study I will be observing patients from OCTOBER
2015 to OCTOBER 2017 in our Hospital. I humbly request you to grant me the ethical clearance
for this study and oblige.
Thanking you,
Yours sincerely,
Dr.Manu Joseph
DATE:
PLACE:

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Dr. Manu Joseph

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