Endovascular coil embolization of ruptured and unruptured intracranial aneurysms: review of a 15 year single center experience in Pakistan.

OBJECTIVE: To assess the outcome of endovascular treatment of intracranial aneurysm over 15 years. METHODS: The retrospective study was conducted at the at Radiology Department of Aga Khan University Hospital, Karachi, and comprised medical records from April 2003 to April 2018 of patients who received endovascular treatment for intracranial aneurysm. Multiple variables reviewed included demographics, clinical presentation, aneurysm morphology, technique used, technique outcome and clinical outcome. Data was analysed using SPSS 22. RESULTS: Of the 242 patients, 111(45.8%) were males and 131(54.1%) were female. The overall mean age was 46.3+/-13.543 years (range: 9-78years). Aneurysm size was <5mm in 95(40.4%) patients, 5-10mm in 98(41.7%) and >10mm in 42(17.9%) patients. Aneurysms were located in the anterior communicating artery in 93(38.4%) patients, internal carotid artery 48(19.8%) patients and posterior communicating artery 26(10.7%) patients. Patients with higher initial Hess and Hunt grade were more likely to have higher modified Rankin scale score after treatment (p=0.001). Overall, 222(91.7%) patients were treated successfully. Complications were noted in 37(15.2%) patients and 10(4.0%) patients died. CONCLUSIONS: No correlation was found between Hess and Hunt grades and aneurysm severity based on aneurysm size, neck and ruptured/unruptured cases.

Hypoglossal Nerve Paraganglioma Depicting as Glomus Tumor of Neck.

INTRODUCTION: Paraganglioma are infrequent neuroendocrine tumors that are most commonly found in the carotid body, ganglia of the vagus, jugular and tympanic nerve. Very rarely they can involve other cranial nerves outside the cranial cavity, we present one such case of hypoglossal nerve paraganglioma in neck. CASE REPORT: A 48 years old male presented with 1-month history of right sided stroke and aphasia. Ultrasonography of neck revealed a highly vascular mass on the right side of the neck. CT angiogram confirmed a highly vascular mass arising above the carotid bifurcation. With the working diagnosis of Glomus tumor, he underwent right sided neck exploration, however, intra-operatively tumor was found to be arising from the hypoglossal nerve instead. Surgery was abandoned on basis of the available literature, with only 6 reported cases in the past 54 years. Patient had no immediate post op complications and was sent for cyber knife treatment. After completion of 5 cycles of cyber knife there was a total of 45% reduction in the size of the paraganglioma with the resolution of the patient's symptoms after a follow up of 6 months. CONCLUSION: Hypoglossal nerve paraganglioma is an uncommon tumor of the neck and can be misdiagnosed with the other tumors in this region especially chemodectoma and glomus tumor. The diagnostic criteria and appropriate treatment modalities have not been established due to the rare presentation hence hypoglossal paraganliomas should be kept in mind when Highly vascular neck mass is encountered.

Image-guided Percutaneous Radiofrequency Ablation for Osteoid Osteoma: Experience from a Developing Nation.

Objective The purpose of this study is to report our experience in using image-guided percutaneous radiofrequency ablation (RFA) for the treatment of osteoid osteoma (OO) and the subsequent duration of pain relief over a period of about six years (May 2013-March 2019; 70 months) at a tertiary-care hospital in a developing nation. Methods A retrospective study was performed at the radiology department of Aga Khan University, Karachi, Pakistan. All patients who had undergone image-guided percutaneous RFA for OO between May 2013-March 2019 were included. All cases had been performed with CT-guidance under general anesthesia, with an additional local anesthesia injection also administered to the patients. A soloist needle had been used for RFA. The primary success rates, complications, symptom-free intervals, and follow-ups were evaluated. Results In total, 15 patients (11 males, 4 females) of a mean age of 13.93 years (range: 5-25 years; median age: 14.5 years) with OO underwent image-guided percutaneous RFA during a period of 70 months. Eleven lesions were located in the femur, three in the tibia, and one in the humerus. The mean nidus size was 8.1 x 5.73 mm [range: (4.9-11.5) x (3.8-9.1) mm]. All patients were successfully treated and experienced resolution of pain in 2.36 months (range: 1-4 months). During the follow-up period (range: 3-40 months; mean: 13.85 months; median: nine months), none of the patients experienced any relapse or persistent symptoms. No major complications were reported. Conclusion Image-guided percutaneous RFA is a minimally invasive and safe treatment option with high efficiency and a high rate of technical success for the treatment of OO. The risk of recurrence is remote with all patients achieving independent recovery.

The Characteristics of Appendicoliths Associated with Acute Appendicitis.

Introduction Differences between appendicoliths associated with appendicitis and those found incidentally have not been studied. The objective of this study was to determine the characteristics of appendicoliths that are associated with acute appendicitis. Methods A cross-sectional study of patients with appendicoliths identified on computed tomographic (CT) scan from January 2008 till December 2014 was conducted. Patients were divided into two group: appendicitis and appendicoliths (AA) and incidentally discovered appendicoliths (IA). Results Overall, 321 patients were included in the study. Of these, 103 (32%) patients were in the AA group while 218 (68%) patients were in the IA group. Both groups were similar in age and gender distribution. Significantly greater proportion of patients in the AA group had more than one appendicolith [AA vs. IA: 63 (62%) vs. 82 (38%), p < 0.001], appendicolith location at the base [AA vs. IA: 34 (33%) vs. 33 (15%), p < 0.001] and appendicolith diameter of 5 mm or more [AA vs. IA: 71 (69%) vs. 28 (13%), p < 0.001]. On multivariate analysis, more than one appendicolith [Odds ratio (OR): 1.9, 95% CI: 1.1-3.4; p = 0.02] and diameter of 5 mm or more (OR: 13, 95% CI: 7.1-23.6; p < 0.001) were independently associated with acute appendicitis. Conclusion Multiple appendicoliths and appendicoliths larger than 5 mm are associated with acute appendicitis.

Factors Associated with Complicated Appendicitis: View from a Low-middle Income Country.

Introduction Factors associated with complicated appendicitis have been inconsistently identified. Moreover, studies are lacking from low and low-middle countries where access to surgical care is limited. Our objective was to identify factors predicting complicated appendicitis as diagnosed intraoperatively in a low-middle income country hospital. Methodology Retrospective case-control study of patients who underwent laparoscopic appendectomy from 01/2008 to 12/2015 was completed. Based on intraoperative diagnosis of complicated appendicitis, patients were divided into two groups; those with complicated appendicitis (CA) and those who had non-complicated appendicitis (NCA). CT scans were further reviewed to identify presence of appendicolith. Result Of the 442 patients included, 88 (20%) patients were in the CA group while 354 (80%) patients were in the NCA group. Patients in the CA group were older [CA vs. NCA: 34.6 ± 14 vs. 30.4 ± 11.5; p-value < 0.001], had symptoms for longer duration [CA vs. NCA: 2 ± 1.2 vs. 1.5 ± 0.8; p-value: 0.001] and had a greater proportion of patients with appendicoliths [CA vs. NCA: 37 (42%) vs. 84 (23.7%); p-value: 0.001]. On multivariable regression analysis, patients with complicated appendicitis had greater odds of having appendicoliths (OR: 2.4, 95% CI: 1.4-4.07; p-value < 0.001) and symptoms for a longer duration (OR: 1.57, 95% CI: 1.25-1.97; p-value < 0.001). Conclusion Patients with complicated appendicitis had greater odds of having appendicoliths and symptoms for a longer duration. Further studies are warranted in low and low-middle income countries to gauge the impact delay in presentation and intervention has on appendicitis and its outcomes.

Cerebrospinal fluid hydrocele caused by scrotal migration of a ventriculoperitoneal shunt.

A 6-month-old boy presented with painless right hemiscrotal swelling. The scrotal ultrasound revealed a cerebrospinal fluid hydrocele caused by the migration of a ventriculoperitoneal shunt (VPS) catheter tip into the right hemiscrotum and associated undescended left testis. Earlier, he underwent a VPS placement for hydrocephalus secondary to neonatal bacterial meningitis and ventriculitis. The patient was treated with bilateral herniotomy, left-sided orchidopexy and repositioning of VPS into the peritoneal cavity.

Non-ionic iodinated contrast-induced sialadenitis with parotid gland sparing in patient of hepatocellular carcinoma.

61-years-old male patient presented with complain of neck swelling and soreness following contrast-enhanced (CE) CT examination with resolution of symptoms in 36-48 hours. He is diagnosed with hepatitis C virus and hepatocellular carcinoma (HCC); already treated with radiofrequency ablation for HCC. He had already undergone two CECT examinations before he was referred to our institution for disease staging/treatment. He also underwent three triphasic CT scan examinations at our institution during the course of treatment for treatment response and staging. Patient remained undiagnosed up to his fourth CT scan due to inability to relate symptoms with contrast administration. The patient was offered close monitoring on fifth CT exam and ultrasound of neck revealed enlarged and echogenic bilateral submandibular glands, however, thyroid and bilateral parotid glands appear unremarkable. This represents transient iodinated contrast induced sialadenitis with sparing of parotid glands.

Risk of appendicitis in patients with incidentally discovered appendicoliths.

BACKGROUND: An appendicolith-related appendiceal obstruction leading to appendicitis is a commonly encountered surgical emergency that has clear evidence-based management plans. However, there is no consensus on management of asymptomatic patients when appendicoliths are found incidentally. The objective of this study was to determine the risk of appendicitis in patients with an incidental finding of the appendicolith. METHODS: A retrospective matched cohort study of patients with appendicolith discovered incidentally on computed tomographic scan from January 2008 to December 2014 at our institution was completed. The size and position of the appendicolith were ascertained. The study group was matched by age and gender to a control group. Both groups were contacted and interviewed regarding development of appendicitis. RESULTS: In total, 111 patients with appendicolith were successfully contacted and included in the study. Mean age was found to be 38 ± 15 y with 36 (32%) of the study population being females. Mean length of appendix was 66 ± 16 mm, and mean width was 5.8 ± 0.9 mm. Mean size of the appendicolith was 3.6 ± 1.1 mm (1.4-7.8 mm). Fifty-eight percent of appendicoliths was located at the proximal end or whole of appendix, 31% at mid area, and 11% at the distal end of appendix. All patients of the study and control groups were contacted, and at a mean follow-up of 4.0 ± 1.7 y, there was no occurrence of acute appendicitis in either group. CONCLUSIONS: Patients with incidentally discovered appendicolith on radiological imaging did not develop appendicitis. Hence, the risk of developing acute appendicitis for these patients does not seem higher than the general population.

A large choledochocystolithiasis mimicking Mirizzi syndrome.

An 18-year-old man presented with spontaneous severe epigastric pain, progressing and radiating to back since 3 days. It was associated with epigastric tenderness, bilious vomiting and jaundice. He had been intermittently experiencing these symptoms for the last 1 year. No known comorbid. Ultrasound showed a poorly visualised heterogeneous focus at porta hepatis; considering poor visualisation, this might represent an enlarged calcified lymph node or cystic duct calculus causing extrinsic compression or a large sludge ball within the common bile duct (CBD), leading to dilatation of common hepatic duct and intrahepatic biliary system. Subsequent magnetic resonance cholangiopancreatography revealed a focal saccular dilatation of middle part of CBD, a type I-B choledochal cyst, large heterogeneous focus seen within it representing choledochocystolithiasis. Later, CT was performed for further characterisation of surrounding anatomy and pathology, which confused the appearance of choledochocystolithiasis for Mirizzi syndrome. Later, surgery and histopathology confirmed type I-B choledochocystolithiasis and chronic cholecystitis.