Pseudoaneurysm of cystic artery stump after laparoscopic cholecystectomy managed successfully with branch hepatic artery embolization using jail technique.

An unusual manifestation caused by cholecystitis, infection, or iatrogenic damage after cholecystectomy is a pseudoaneurysm of the cystic artery. We report this rare illness in a 64-year-old man who visited the emergency room with hematemesis and anemia. The patient initially experienced acute cholecystitis and then underwent a laparoscopic cholecystectomy following which he developed a cystic artery pseudoaneurysm, secondary to infected fluid collection. Based on the patient's history and contrast-enhanced computer tomography abdomen, a diagnosis of pseudoaneurysm of the cystic artery was made. Angioembolization of the hepatic artery branch was performed to occlude the pseudoaneurysm.

IgG4-related inflammatory pancreatic head pseudotumor mirrors pancreatic head tumor: A novel case series with a review of the literature.

Key Clinical Message: In this noteworthy case series regarding pancreatic pseudo tumors, we intend to spread knowledge among physicians for the diagnostic and therapeutic approach and eventual disease prognosis. Abstract: Inflammatory pseudotumor of pancreatic head greatly mimics pancreatic head tumor. One of them is IgG4-related pancreatic disease, which is commonly mistaken as neoplastic disease on imaging. In our novel case series, we report three cases of IgG4-related pancreatic head pseudotumor with patients ranging from 35 to 72 years of age. Patients presented with jaundice and abdominal pain. Alongside initial laboratory workup, abdominal CTs and serum IgG4 levels were also obtained. Imaging features in conjunction with IgG4 levels confirmed the diagnosis of IgG4-related autoimmune pancreatitis. Pancreatic pseudotumors are notorious for being often reported as real tumors. Through our noteworthy case series, we intend to highlight the imaging features and laboratory markers that are crucial in such cases to avoid invasive procedures.

The tendency of segmental distribution of hepatic metastasis according to couinaud classification: a comparison of portal versus systemic route of metastatis due to primary colorectal and breast tumors.

Objective: The liver is the commonest site of metastatic disease for patients with colorectal cancer (CRC), with at least 25% of patients developing liver metastasis (LM) during their illness. About 50% of patients diagnosed with metastatic breast cancer develop LM, and 5-12% of these patients develop LM as the main site of breast cancer recurrence. This study aims to determine the frequency of segmental distribution of LM seeding from portal versus systemic routes of dissemination due to primary CRC and breast carcinoma, respectively. Material and methods: This retrospective study was conducted in a tertiary care teaching hospital in Pakistan. Ethical approval was taken from the institutional review board. A total of 587 patients were included in the study with 297 CRC patients with LM and 300 breast carcinoma patients with LM. Segment I involvement was excluded from the calculation because of the dual blood supply. Patients' detailed demographics and other information were collected on a predesigned proforma. The authors evaluated axial and multiplanar reformatted computed tomography images for LM and CRC metastasis. Data analysis was done using SPSS version 25. P value less than or equal to 0.05 was considered statistically significant. Results: A study population of 587 patients was employed that comprised 287 CRC and 300 breast carcinoma patients. There were 179 (30.5%) male and 408 (69.5%) female patients. The mean age of patients was 54.9±13.3. The study revealed that 204 (34.8%) CRC patients showed right lobe (V, VI, VII, VIII) and 83 (14.1%) CRC patients showed left lobe involvement of metastasis while 192 (32.7%) breast carcinoma patients showed right lobe involvement and 108 (18.4%) breast carcinoma patients showed left lobe involvement in metastasis (P=0.02). We also found 40 (6.8%) colorectal and 55 (9.4%) breast carcinoma patients showed left lateral segment (II, III) involvement. Medial segment involvement (IV) was seen in 43 (7.3%) CRC patients and 53 (9%) breast carcinoma patients (P=0.03). Conclusion: The right hepatic lobe is the predominant site of metastasis independent of the portal or systemic route of dissemination in primary carcinoma. Moreover, in left lobe metastasis medial segment (IV) is more affected in CRC while the lateral segment (II, III) is more affected in breast carcinoma.

Use of National Institute for Health and Care Excellence head injury guidelines among patients with delayed presentation after head trauma can lead to missed traumatic brain injury: a 5-year institutional review.

Introduction: In 2014, traumatic brain injury (TBI) caused 3 million ER visits, hospitalizations, and deaths in the US. The National Institute for Health and Care Excellence (NICE) guidelines, initially generated using data from patients presenting within 24 h of head trauma, are used to determine the need for head computed tomography (CT) scan in patients after 24 h. The authors wanted to determine the proportion of CT scans for head trauma performed at our center in late presenters (>24 h after head trauma), the incidence of intracranial pathology in early (24 h) versus late (>24 h) presenters, and the sensitivity of the NICE guidelines for TBI in these two subpopulations. Methods: A retrospective chart review was conducted at a tertiary care center in Karachi. All people (>16) who had a head CT for head trauma from 2010 to 2015 were included. Age, sex, primary diagnosis, comorbid disorders, mechanism-of-injury, duration (in hours) from head trauma to presentation, site, and extent of injury (injury severity scale), hospital stay, number and details of surgical procedures, CT scan findings, other injuries, and mortality were recorded. Means were compared using the Independent Sample t-test, while categorical variables were compared using χ2. Multivariate logistic regression analyses were used to identify TBI predictors. Results: The authors found 2009 eligible patients; seven were excluded due to incomplete medical records. The final statistical analysis comprised 2002 head trauma patients. Overall, 52% of early and late presenters had severe injuries, and 2.3% died. 32.2% of patients with head trauma had CT after 24 h. Early presenters were 46.7% traumatized, while late presenters were 63%. The NICE guidelines were 93% sensitive for early presenters and 83% for late presenters with traumatic intracranial injury. Conclusion: Patients coming to the emergency department after 24 h of head trauma are a large proportion of the overall head trauma population. The NICE guidelines for late-presenting head injuries are less sensitive and may overlook intracranial injuries if imaging is not performed.

Wandering spleen with acute torsion mimicking an adnexal mass.

Wandering spleen manifests when the splenic ligaments are underdeveloped, or become lax, thereby allowing the spleen to relocate from its anatomical site to more distant areas. During such movements, torsion of the long splenic peduncle is common, which can lead to symptoms of acute abdomen and further complications such as infarction. It is typically seen in children and young females. Our report presents a case of a 22-year-old female presenting to the ER with complaints of severe pain in the abdominal region. On ultrasound, there was suspicion of an adnexal mass, which was later confirmed to be a misplaced spleen in the lower abdomen, with torsion, fat stranding, and splenic vein thrombosis, as revealed by enhanced CT abdomen and pelvic MRI. It was followed by an emergency splenectomy. As wandering spleen presents nonspecifically and is a rare condition, it is important to consider wandering spleen when patients present similarly to this case, to prevent misdiagnosis and to deliver surgical treatment quickly to preserve the spleen.

Knowledge assessment of radiologists, radiology residents, and radiographers regarding contrast materials and management of adverse drug reactions occurring due to contrast materials: a cross-sectional study.

The purpose of this study was to assess the knowledge of the radiology personnel regarding contrast media used in radiology and the management of associated adverse drug reactions. Methods: A questionnaire-based cross-sectional study was conducted from 21 February to 31 March 2019 in five major hospitals of Peshawar, Pakistan. A 30-item questionnaire was adopted from the existing literature containing both open and closed-ended questions and the authors conducted a pilot study among 25 participants to assess the face validity of the tool. A universal sampling technique was adopted. Descriptive statistics were used to summarize the findings of the study. Results: Less than half of the participants could correctly classify iodinated contrast media used in radiology on the basis of ionicity and osmolaity. Sixty-three percent chose severe contrast material-induced allergic reaction as type I hypersensitivity reaction while almost half of them correctly identified the features of iodinated contrast media associated with lesser side effects. Very few of them (6.7%) had read the ACR 2018 manual on contrast media. Regarding the risk factors for acute adverse reactions and signs/symptoms of anaphylaxis few could answer satisfactorily. Twenty-eight percent of participants correctly identified epinephrine as the initial medication in an anaphylactic reaction. Regarding the preferred route of administration, concentration and dose of epinephrine, the participants' correct response was quite poor (43.8%, 6.7%, and 8.6%, respectively). More than 65% of participants could name a single intravenous corticosteroid and antihistamine. Conclusion: Radiology personnel's knowledge regarding contrast material and management of severe contrast material-induced allergic reactions is unsatisfactory.

Prevalence and antimicrobial susceptibility of Acinetobacter spp. in a tertiary care hospital in Peshawar: a cross-sectional study.

Acinetobacter spp. have been a primary cause of nosocomial infections worldwide, causing significant morbidity and mortality, especially in Pakistan. The purpose of this study was to investigate the trend of antimicrobial resistance over a 5-year period in a tertiary care hospital in Pakistan. Methods: A retrospective cross-sectional study regarding the occurrence and antimicrobial resistance of Acinetobacter spp. recovered from clinical specimens that were referred to the Pathology Laboratory of Northwest General Hospital, Peshawar. The data from 2014 to 2019 was recorded and analyzed by the laboratory. Sociodemographic characteristics and laboratory record data was analyzed using SPSS, version 25. A chi-square test was applied to see the significance. Results: Of 59 483 clinical samples, Acinetobacter baumannii strains were detected in 114 of them. The majority of the clinical samples were from blood (89.5%) followed by sputum (7.9%), wound swab (1.8%), and bone marrow (0.9%). A. baumannii has been found in 52 men (67.53%) and 28 women (75.67%), with an overall risk of 0.669 times. In 76 men (98.70%), sensitivity for ertapenem (99.1), colistin (96.49), and tigecycline (78.9%) were also observed which indicated the potential viability of these drugs to treat multidrug-resistant (MDR) Acinetobacter infections. The male-to-female risk ratio was 0.98 for colistin and 0.71 for amikacin. Conclusion: Increased frequency of MDR supports the need for continuous surveillance to determine the prevalence and evolution of MDR Acinetobacter spp. in Pakistan. Colistin, tigecyclines, and ertapenem remain the possible line of drugs to treat MDR Acinetobacter.

Does sevoflurane sedation in pediatric patients lead to "pseudo" leptomeningeal enhancement in the brain on 3 Tesla magnetic resonance imaging?

BACKGROUND: Prominent leptomeningeal contrast enhancement (LMCE) in the brain is observed in some pediatric patients during sedation for imaging. However, based on clinical history and cerebrospinal fluid analysis, the patients are not acutely ill and do not exhibit meningeal signs. Our study determined whether sevoflurane inhalation in pediatric patients led to this pattern of 'pseudo' LMCE (pLMCE) on 3 Tesla magnetic resonance imaging (MRI). AIM: To highlight the significance of pLMCE in pediatric patients undergoing enhanced brain MRI under sedation to avoid misinterpretation in reports. METHODS: A retrospective cross-sectional evaluation of pediatric patients between 0-8 years of age was conducted. The patients underwent enhanced brain MRI under inhaled sevoflurane. The LMCE grade was determined by two radiologists, and interobserver variability of the grade was calculated using Cohen's kappa. The LMCE grade was correlated with duration of sedation, age and weight using the Spearman rho rank correlation. RESULTS: A total of 63 patients were included. Fourteen (22.2%) cases showed mild LMCE, 48 (76.1%) cases showed moderate LMCE, and 1 case (1.6%) showed severe LMCE. We found substantial agreement between the two radiologists in detection of pLMCE on post-contrast T1 imaging (kappa value = 0.61; P < 0.001). Additionally, we found statistically significant inverse and moderate correlations between patient weight and age. There was no correlation between duration of sedation and pLMCE. CONCLUSION: pLMCE is relatively common on post-contrast spin echo T1-weighted MRI of pediatric patients sedated by sevoflurane due to their fragile and immature vasculature. It should not be misinterpreted for meningeal pathology. Knowing pertinent clinical history of the child is an essential prerequisite to avoid radiological overcalling and the subsequent burden of additional investigations.

High-altitude cerebral edema manifesting as T2/FLAIR hyperintensity and microbleeds in the white matter on MRI brain.

High-altitude cerebral edema is a rare type of acute mountain illness characterized by consciousness disruption and truncal ataxia. Here we discuss a 40-year-old nondiabetic, nonsmoker male who went on a tour to Nanga Parbat. On returning home, the patient developed symptoms of headache, nausea, and vomiting. His symptoms worsened with time and he developed lower limb weakness and shortness of breath. Later, he underwent a computerized tomography chest scan. On the basis of CT scan findings, the doctors decided that the patient was suffering from COVID-19 Pneumonia despite having negative COVID-19 PCR tests multiple times. Later, the patient presented to our hospital with similar complaints. MRI of the brain revealed T2/fluid-attenuated inversion recovery hyperintense and T1 hypointense signals in the bilateral semioval centrum, posterior periventricular white matter, and corpus callosum genu, body, and splenium. These abnormal signals were discovered to be more evident in the corpus callosum's splenium. Moreover, susceptibility-weighted imaging revealed micro hemorrhages in the corpus callosum. This verified the diagnosis that the patient is suffering from high-altitude cerebral edema. Within 5 days, his symptoms resolved and he was discharged with full recovery.

Testicular choriocarcinoma with small bowel metastasis and active gastrointestinal bleeding.

Testicular choriocarcinomas make up less than 1% of all germ-cell tumors and are highly malignant, attributable to hematogenous spread. While the most common sites of metastasis are the lungs and liver, metastatic spread to the gastrointestinal tract is rare wherein patients may present with GI distress or even an upper GI bleed. In this report, we present a case of known testicular choriocarcinoma in a 40-year-old male who presented to the emergency room with severe anemia and a suspected upper GI bleed.

Clinical Utility of S.T.O.N.E, Guy's Scoring System, and Renal Stone Complexity Scoring in Predicting Outcome of Single-Tract Percutaneous Nephrolithotomy.

BACKGROUND: Several imaging-based scores have been developed to predict postoperative stone-free state (SFS) and complications. This study aimed to assess the accuracy of the S.T.O.N.E., Guy Scoring System (GSS), and Seoul National University Renal Stone Complexity (S-ReSCS) scores in predicting the outcomes of single-tract percutaneous nephrolithotomy (ST-PCNL). This scoring system holds paramount importance for low-income and low-middle-income countries (LMICs), as it is inexpensive and cost-effective for the healthcare system. METHODOLOGY: This retrospective study was carried out with 147 participants. Based on the preoperative computerized tomographic (CT) scan, each patient's S.T.O.N.E. score, GSS, and S-ReSCS were recorded. The modified Clavien grading system was used to document intra- and postoperative complications. RESULTS: The mean age of the sample population was 45 years. SFS was achieved in 110 (74.8%) patients. The number of calyces involved (p = 0.008), S.T.O.N.E. scoring (p = 0.001), GSS (p = 0.008), and S-ReSCS (0.001) correlated well with the SFS. Forty-nine (33.33%) patients developed complications. The most common complications fell within Clavien grade II. No statistical significance was noted between the S.T.O.N.E. score, GSS, and S-ReSCS with the modified Clavien grading system. CONCLUSION: The S.T.O.N.E. scoring, GSS, and S-ReSCS have a high predictive value for achieving SFS in ST-PCNL. In addition, findings from LMICs are comparable with those from the rest of the world.

Color doppler ultrasound for diagnosis of testicular carcinoma: A comparison with gold standard histopathology.

Introduction: Testicular carcinoma is the most common cancer among males aged 15-34 years. The known risk factors for testicular cancer include undescended testis (cryptorchidism), testicular dysfunction, perinatal factors and prior history of cancer in one testis. We aimed to determine the diagnostic accuracy of color doppler ultrasound in diagnosis of testicular carcinoma using histopathology as GOLD STANDARD. Method: ology: A cross sectional study was conducted from July 2015 to Feb 2016 at the Department of Radiology, Jinnah Post Graduate Medical Center, Karachi. 311 subjects were selected through inpatient/outpatient or emergency department. Patients were evaluated for testicular carcinoma by color doppler ultrasound on Toshiba nemio. Finding of color doppler ultrasound was compared with histopathology. True positive, true negative, false positive, false negative as per operational definition was determined. Results: Mean age of the patients of the study was 41.76 ± 8.11 (30-50) and mean and SD of Duration of symptoms was 5.5 ± 3.5 (4-15) months. Of 175(56.27%) subjects diagnosed as testicular carcinoma on CDUS, only 160(48.55%) were subsequently found to have testicular carcinoma. sensitivity of CDUS in diagnosing scrotal diseases was 88.8% while specificity was 78.1%. Conclusion: We conclude that CDUS is an excellent, safe, and reliable method for evaluating patients with testicular carcinoma. It helps to improve patient's management, especially by preventing unnecessary surgical exploration. It is also convenient and easy to perform. But it has its own limitations, and requires adequate expertise and experience. Its results are also equipment dependent.

Interobserver reliability between pediatric radiologists and residents in ultrasound evaluation of intraventricular hemorrhage in premature infants.

BACKGROUND: Germinal matrix intraventricular hemorrhage (IVH) may contribute to significant morbidity and mortality in premature infants. Timely identification and grading of IVH affect decision-making and clinical outcomes. There is possibility of misinterpretation of the ultrasound appearances, and the interobserver variability has not been investigated between radiology resident and board-certified radiologist. AIM: To assess interobserver reliability between senior radiology residents performing bedside cranial ultrasound during on-call hours and pediatric radiologists. METHODS: From June 2018 to June 2020, neonatal cranial ultrasound examinations were performed in neonatal intensive care unit. Ultrasound findings were recorded by the residents performing the ultrasound and the pediatric attending radiologists. RESULTS: In total, 200 neonates were included in the study, with a mean gestational age of 30.9 wk. Interobserver agreement for higher grade (Grade III & IV) IVH was excellent. There was substantial agreement for lower grade (Grade I & II) IVH. CONCLUSION: There is strong agreement between radiology residents and pediatric radiologists, which is higher for high grade IVHs.

Inpatient assessment of the neurological outcome of acute stroke patients based on the National Institute of Health Stroke Scale (NIHSS).

Objective: Identify the association between stroke severity and the neurological outcome of an acute stroke using the National Institutes of Health stroke scale (NIHSS). Study design: A descriptive cross-sectional study.Place and duration of study: Northwest hospital Hayatabad Peshawar. Methodology: A cross-sectional descriptive study was done in the general plus stroke unit of the northwest hospital in Peshawar, KPK during Jan 2022 to July 2022.400 admitted patients diagnosed with acute stroke in the past three months were included for NIHSS assessment and were classified as mild, moderate, or severe stroke. After entering all of the data from the collection into SPSS version 16, the information was transferred to an Excel spreadsheet. To further assess the results, the researcher and statistician evaluated all of the cases, radiological findings, and laboratory test data. Results: In this cross-sectional descriptive study, 400 individuals ranging from 30 to 90 years of age were divided into two groups: males and females. The survey was conducted by 49% of men and 51% of women. The stroke severity was assessed to be mild in 22% of cases, moderate in 49%, and severe in 29% of patients. As evaluated by the NIHSS, Patients with acute ischemic stroke were divided into four groups depending on their neurological outcomes: those who improved were 160 (40%), those who remained stable were 124 (31%), and those who deteriorated were 52 (13%), and those who died were 64 (16%). Patients with greater triglyceride levels were 88, while those with lower levels were 312. Acute stroke was also detected in 34% of patients with a covid history, 28% of patients who were covid positive, and 38% of patients who were covid free in this investigation. Conclusion: According to our findings, the NIHSS is a reliable scale for evaluating patients' neurological outcomes and determining the association between acute stroke severity and cognitive functioning (NIHSS).

Oculomotor nerve palsy in neurofibromatosis type 2.

Neurofibromatosis (NF) type 2 is a rare neurological, autosomal dominant and genetic disorder. It is caused by a mutation in the tumor suppressor gene, called NF2 gene. The disorder results in several benign tumors of the nervous system. These typically include vestibular schwannomas, meningiomas, and ependymomas. Multiple cranial nerve abnormalities affect the brain, spinal cord, nerves, and skin and cause significant morbidity in patients. We describe a 20-year-old patient, with a family history of brain tumors, with symptoms of left sided third nerve palsy. Magnetic Resonance Imaging (MRI) of the brain and orbits revealed a small sized cavernous sinus meningioma and bilateral vestibular schwannomas. As per the differential diagnosis and optimal resolution brain imaging, NF2 was diagnosed. The patient was referred for specific treatment to the neuro-oncology unit. The case is distinct as the patient presented with a parasellar meningioma leading to third nerve palsy besides bilateral vestibular schwannomas. Manchester criteria and high contrast MR imaging proved more beneficial in our patient for the diagnosis of a wider clinical spectrum of NF2.

Safety and Adequacy of Ultrasound-Guided Percutaneous Renal Biopsy in Children: A Single-Center Experience.

Background Ultrasound-guided percutaneous renal biopsy (PCRB) is a commonly used technique to obtain renal tissue for histopathological diagnosis in children and adolescents. The objectives of this study include determining the indications for renal biopsy, documenting the safety and efficacy of ultrasound-guided PCRB, and documenting its complications along with histopathological findings in children. Methodology The Ethical Review Committee approved this cross-sectional study. Data of all children with either nephrotic or nephritic syndrome from January 2017 to September 2020 (at The Kidney Center Post Graduate Training Institute Karachi) who underwent ultrasound-guided PCRB were collected and analyzed. An ultrasonic examination was performed both before and after the biopsy. Results During the research period, 104 individuals underwent PCRB. The average age of the children biopsied was 7.44 ± 4.12 years (range = 1-17 years). The most prevalent reason for biopsy was nephrotic syndrome. Almost 94% of PCRBs were effective. Post-biopsy complications were detected in 16 cases, with peri-nephric hematoma being the most prevalent. Conclusions In children, ultrasound-guided PCRB can safely be performed under sedation in experienced hands with an automated biopsy gun needle. The use of real-time ultrasound guidance as well as the automated biopsy gun ensures good outcomes.