Rupture of an acute ascending aortic dissection causing right pulmonary artery occlusion.

Rupture of ascending thoracic aortic dissection mimicking pulmonary thromboembolism due to pulmonary artery occlusion is rare and should be considered in hypoxic patients with aortic dissection.

Giant parapharyngeal high-flow arteriovenous malformation causing airway compromise: emergency embolo-sclerotherapy via an endovascular-only approach.

Head and neck arteriovenous malformations are the commonest extracranial vascular malformations but demonstrate a unique challenge in the limited available surgical options secondary to their intimate association to vital structures. We present a case of middle-aged female patient who presented with threatened upper-airway obstruction and bleeding secondary to a slowly enlarging parapharyngeal arteriovenous malformations. She was treated with an endovascular-only approach with the proximal arteriole branches selectively undergoing embolo-sclerotherapy with an optimal radiological and clinical outcome. We also demonstrate the utility of elective tracheostomy prior to intervention.

Pulmonary artery pseudoaneurysm secondary to COVID-19 treated with endovascular embolisation.

Pulmonary artery pseudoaneurysms are uncommon and can cause severe, life-threatening haemoptysis. We present a case of a 74-year-old gentleman who was being treated for COVID-19 pneumonitis and a concomitant segmental pulmonary artery thrombus with conventional treatment and anticoagulation. The patient developed significant haemoptysis during admission. A repeat computed tomography pulmonary angiogram revealed an 8 mm left upper lobe pulmonary artery pseudoaneurysm. Anticoagulation was withheld and the pseudoaneurysm was successfully treated with endovascular embolisation with an Amplatzer® IV plug, leading to resolution of the haemoptysis. To our knowledge this is the first case of a pulmonary artery pseudoaneurysm secondary to COVID-19.

Illuminating the nidus: The role of FDG PET/CT in high flow arteriovenous vascular malformations.

The appropriate identification and localization of a nidus of a high flow arteriovenous malformation is crucial to guide targeted interventional therapy. However, the nidus of a complex or previously treated HFAVM can be difficult to non-invasively demonstrate on magnetic resonance imaging alone. We describe a unique case of a 56-year-old female with a complex high flow arteriovenous malformation in which we demonstrated the feasibility of fluorodeoxyglucose positron emission tomography/computed tomography to non-invasively delineate the nidus which subsequently guided successful targeted interventional therapy.

Treatment of Primary Craniofacial Hyperhidrosis: A Systematic Review.

BACKGROUND: Primary craniofacial hyperhidrosis (CH) can have a profoundly negative impact on quality of life. No comprehensive review of its management exists. OBJECTIVE: The objective of this review is to present the best clinical evidence to guide CH management. METHODS: A systematic review was performed using PRISMA guidelines. MEDLINE and EMBASE were searched from 1966 to 2014 for articles using the MeSH terms "Hyperhidrosis", "Head", "Neck" and synonymous text words. Inclusion criteria were experimental and observational studies addressing CH treatment. Two reviewers independently assessed study quality and analysed data. RESULTS: Of 833 references yielded, 27 met inclusion criteria and were analysed. Twenty-two studies evaluated T2 sympathetic ablation (Level III evidence). Outcome measures were subjective and mean follow-up was 29 months. Reported efficacy was high (70-100%), recurrence rates were generally low (0-8%) and complications largely transient (e.g. pneumothorax 0-1%). However, 8-95.4% experienced troubling compensatory sweating. One randomised controlled trial and one observational study evaluated botulinum toxin A (Level Ib and III, respectively). Both employed objective outcome measures and demonstrated similar findings. Efficacy was 100%, lasted a median of 5-6 months and frontalis muscle inhibition was the main adverse effect (50-100%). Three studies evaluated anticholinergic therapy: topical glycopyrrolate demonstrated high efficacy (96%) with minimal adverse effects (Level Ib) and oral oxybutynin demonstrated relatively high efficacy (80-100%) but with noticeable adverse effects (76.6-83.6%) (Level III). CONCLUSION: There are few quality studies evaluating CH treatment. Based on available evidence, we recommend topical glycopyrrolate, oral oxybutynin and intradermal botulinum toxin A as first-line therapies due to their efficacy and safety. T2 sympathectomy should be considered for patients refractory to first-line therapy.

Toxic megacolon during pregnancy in ulcerative colitis: A case report.

INTRODUCTION: Ulcerative colitis is an idiopathic inflammatory bowel condition whose peak incidence coincides with fertility in female patients. In pregnancy, acute fulminant colitis is rare, and, when it becomes refractory to maximum medical therapy, emergency colectomy is mandated. Over the past quarter century, there have been few reports of this rare event in the literature. PRESENTATION OF CASE: We report a 26 year old primigravida female who presented with toxic megacolon during the third trimester of pregnancy, unresponsive to medical therapy. She subsequently underwent an urgent low transverse caesarean section with a total colectomy. Both mother and child made a satisfactory recovery post operatively. DISCUSSION: Although the fetus is at higher risk than the mother in such a circumstance, morbidity and mortality rates are still noticeably high for both, and therefore, prompt diagnosis is key. CONCLUSION: It is imperative that female patients planning to conceive with a known diagnosis of ulcerative colitis liaise with their obstetricians and gastroenterologists early to optimise medical treatment to prevent the development of a toxic megacolon and that conception is planned during a state of remission. Should surgical intervention become required, this can be performed with favourable outcomes for mother and child, as demonstrated in this report.

Resection of a large carotid paraganglioma in Carney-Stratakis syndrome: a multidisciplinary feat.

A 39-year-old man was referred to the vascular surgeons with a right-sided cervical mass, palpitations, headaches and sweating. He had presented with abdominal discomfort 12 months earlier. Investigations had revealed a gastrointestinal stromal tumour (GIST) and left adrenalectomy. CT of the neck with contrast demonstrated a large right carotid paraganglioma, extending superiorly from below the carotid bifurcation to encase the internal carotid artery. Genetic screening confirmed the diagnosis of Carney-Stratakis syndrome, an SDH-D germline mutation leading to GIST and multifocal paragangliomas. Successful surgical excision required considerable multidisciplinary teamwork between neuroendocrinologists, anaesthetists and surgeons. The tumour was highly vascular and involved the right carotid body, hypoglossal and vagus nerves. Access was challenging and maxillofacial surgical expertise were required for division of the mandible. The patient made a good recovery following speech and swallowing rehabilitation.

Using Diffusion-Weighted Magnetic Resonance Imaging to Confirm a Diagnosis of Posterior Ischaemic Optic Neuropathy: Two Case Reports and Literature Review.

Posterior ischaemic optic neuropathy is a rare cause of visual loss believed to be due to infarction in the territory of the pial branches of the ophthalmic artery. The disorder most commonly occurs in the context of prolonged surgery or giant cell arteritis, and the absence of clinical signs in the eye means that the diagnosis is one of exclusion. Here, we present two cases studies of patients who developed posterior ischaemic optic neuropathy confirmed by the observation of secondary changes on diffusion-weighted imaging sequences. In the first case visual loss followed robotic pelvic surgery, and in the second case it was associated with multiorgan dysfunction secondary to severe pancreatitis. Our cases demonstrate that in the right clinical context, diffusion-weighted imaging can provide a positive diagnosis of acute posterior ischaemic optic nerve injury in the acute phase.