High-Resolution Computed Tomography and Intraoperative Correlation in Cholesteatoma: Enhancing Preoperative Evaluation and Surgical Management.

INTRODUCTION: Cholesteatoma, a hazardous non-neoplastic lesion of the temporal bone, is prevalent in socio-economically disadvantaged groups in developing nations like India. Timely detection and surgical intervention are essential for effective management. High-resolution computed tomography (HRCT) has revolutionized the assessment of temporal bone pathology, though its role in preoperative evaluation remains debated. This study aimed to validate HRCT's utility in diagnosing cholesteatoma, compare its findings with intraoperative observations, and assess sensitivity and specificity. METHODS: This diagnostic accuracy study was conducted at a tertiary care center in Western India, from March 2021 to November 2022. HRCT findings of 54 cholesteatoma patients were evaluated and compared with intraoperative findings. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, and Cohen's kappa coefficient were calculated. RESULTS: HRCT demonstrated a sensitivity exceeding 90% in identifying scutum erosion, mastoid sclerosis, and abnormalities in the tympanic membrane, along with a specificity surpassing 90% in detecting various conditions, including facial canal erosion, sinus plate erosion, lateral semicircular canal erosion, erosion of the posterior wall of the external auditory canal, and abnormalities in the tympanic membrane. Furthermore, HRCT exhibited an accuracy of over 90% in detecting most pathologies. There was a perfect or near-perfect agreement observed for abnormal tympanic membrane, sinus plate erosion, mastoid sclerosis, and erosion of the posterior wall of the external auditory canal (with kappa values > 0.8). Moderate to fair agreement was noted for other pathologies. CONCLUSION: HRCT offered precise detection of the majority of pathologies, thereby facilitating surgical planning. However, the presence of limitations in distinguishing specific abnormalities highlights the significance of utilizing HRCT in tandem with other diagnostic modalities to ensure meticulous diagnosis and effective treatment planning.

Endovascular management of portal steal syndrome due to portosystemic shunts after living donor liver transplantation.

BACKGROUND AND AIM: After liver transplant, pre-existent porto-systemic shunts (PSS) may persist, causing "portal steal," leading to graft dysfunction, hepatic encephalopathy (HE), and eventual rejection. In recipients of small-for-size transplant liver grafts, shunts may be created intraoperatively, facilitating diversion of portal flow to systemic circulation to avoid ill-effects of portal overperfusion. These iatrogenic shunts may also subsequently lead to portal steal. We aim to evaluate safety and efficacy of endovascular techniques in management of portal steal due to PSSs in living donor liver transplantation (LDLT) recipients. METHODS: Between 2013 and 2020, we encountered five LDLT recipients with large PSS, who presented with graft dysfunction and/or HE. One patient had a surgically created shunt and four had spontaneous shunts, not surgically ligated during transplant. Endovascular techniques including plug-assisted or balloon-occluded retrograde transvenous obliteration (PARTO/BRTO) or covered inferior vena cava (IVC) stent grafts were to occlude these PSS and counter the portal steal in all patients. Technical success and clinical outcomes at 1-year-follow-up were assessed. RESULTS: Imaging showed large PSS causing portal steal syndrome in all five patients. IVC stent graft was used to isolate the shunt in two patients and PARTO/BARTO was performed in three patients. One patient had guarded prognosis due to multiple organ dysfunction and died 5 days after endovascular procedure. At 1-year follow up, graft functions normalized in four patients with no recurrence of HE. No procedure-related complications were seen. CONCLUSION: Endovascular techniques can be safely and effectively used to counter portal steal syndrome in LDLT recipients, thus avoiding surgical re-exploration in these patients.

Radiofrequency Ablation of Parathyroid Adenomas: Safety and Efficacy in a Study of 10 Patients.

PURPOSE: To evaluate safety and effectiveness of ultrasound-guided percutaneous radiofrequency ablation of parathyroid adenoma in surgically unfit patients with hypercalcemia because of hyperparathyroidism. MATERIALS AND METHODS: A retrospective review of hospital records from Jan 2012 to Dec 2018 revealed 10 patients, who had undergone ablation for solitary parathyroid adenoma. All 10 patients suffered from hyperparathyroidism because of parathyroid adenoma, resulting in hypercalcemia. These patients were surgically unfit because of comorbidities. Pre-ablation serum calcium and serum parathormone levels were measured and compared with the levels after the ablation. RESULTS: Mean serum calcium level decreased significantly from 2.81 ± 0.17 mmol/L pre-ablation to 2.42 ± 0.17 mmol/L 72 h after ablation and parathyroid hormone levels became normal in all patients within 7 days. Seven patients remained normo-calcaemic at 6 months follow-up with no signs and symptoms of hyperparathyroidism. One patient with pancreatitis died after 15 days because of pre-existing multi-organ failure. Two patients were lost to follow-up before 6 months. CONCLUSION: Radiofrequency ablation of parathyroid adenoma is a safe and effective alternate treatment method for symptomatic hypercalcemia in surgically unfit patients suffering from primary hyperparathyroidism because of parathyroid adenoma.

Results of Portosystemic Shunt Embolization in Selected Patients with Cirrhosis and Recurrent Hepatic Encephalopathy.

BACKGROUND: Large portosystemic shunts (PSSs) may lead to recurrent encephalopathy in patients with cirrhosis and embolization of these shunts may improve encephalopathy. MATERIAL AND METHODS: Five patients underwent balloon-occluded retrograde transvenous obliteration (BRTO) or plug-assisted retrograde transvenous obliteration (PARTO) of a large PSS at our center in last 2 years for recurrent hepatic encephalopathy (HE) at a tertiary care center at north India. Data are shown as number and mean ± SD. None of these patients had Child's C cirrhosis or presence of large ascites/large varices. RESULTS: Five patients (all males), aged 61 ± 7 years, underwent BRTO or PARTO for recurrent HE and presence of lienorenal (n = 4) or mesocaval shunt (n = 1). The etiology of cirrhosis was cryptogenic/non-alcoholic steatohepatitis in 3, and alcohol and hepatitis B in one each. All patients had Child's B cirrhosis; Child's score was 8.6 ± 0.5, model for end-stage liver disease (MELD) score was 13.4 ± 2.3. One patient had mild ascites; 3 patients had small esophageal varices before procedure. Sclerosants (combination of air, sodium tetradecyl sulphate, and lipiodol) were used in two patients, endovascular occlusion plugs were used in two patients, and both sclerosants and endovascular occlusion plug were used in one patient. Embolization of minor outflow veins to allow for stable deposition sclerosants in dominant shunt was done using embolization coils and glue in two patients. One patient needed 2 sessions. The pre-procedure ammonia was 127 ± 35 which decreased to 31 ± 17 after the shunt embolization. There was no recurrence of encephalopathy in any of these patients. One patient was lost to follow-up at 6 months; others are doing well at 6 months (n = 2), 10 months (n = 1) and 2 years (n = 1). None of these patients developed further decompensation in the defined follow-up period. CONCLUSION: Good results can be obtained in selected patients after embolization of large PSS for recurrent HE.

Percutaneous thrombin injection under sonographic guidance for exclusion of non-catheterizable post-pancreatitis pseudoaneurysm of the superior mesenteric artery: a minimally invasive and expeditious treatment option.

Post-pancreatitis pseudoaneurysms are not uncommon. They have a high associated mortality due to a propensity to rupture. Current standards of treatment advocate immediate intravascular interventions. We describe two cases of alcohol-related post-acute pancreatitis pseudoaneurysms arising from the second-order branches of the superior mesenteric artery (SMA) that were endoluminally inaccessible. Both cases were successfully treated with percutaneous thrombin injection into the pseudoaneurysm sac under ultrasound guidance. We suggest that endoluminally inaccessible pseudoaneurysms that are percutaneously accessible can be expeditiously treated with percutaneous thrombin injection. Further, due to the efficaciousness of this procedure, it could be considered as a first-line minimally invasive therapeutic option.

Cerebral encephalopathy with extrapontine myelinolysis in a case of postpartum hypernatremia.

Extrapontine myelinolysis, a fairly common metabolic disorder, is associated with neurological complications. Central pontine and extrapontine myelinolysis are commonly recognized with rapid correction of sodium. Myelinolysis, however, has rarely been described with hypernatremia. We report a rare case of post-partum hypernatremic encephalopathy associated with serum sodium levels as high as 200 mEq/l on presentation. Although the serum sodium levels were brought down gradually, subsequent imaging showed progression of demyelination and deterioration of the neurological status.

Cavernous hemangioma located at the foramen of Monro: Radiopathological correlation.

Intraventricular cavernous hemangiomas are rare. Amongst them, cavernomas located at the foramen of Monro are of greater interest because of their rare location, varied symptoms, and often association with hydrocephalus. We present a rare case of cavernous hemangioma located at foramen of Monro, with its radiopathological confirmation.

Case report: Filariasis presenting as an intra-abdominal cyst.

Filariasis is an endemic infection seen in the tropical and subtropical regions of the world, presenting with lymphatic dysfunction in the form of lymphocele, hydrocele, chyluria, or groin lymphadenovarix. We report a rare presentation of filariasis as an intra-abdominal cystic mass.