Role of Preoperative Embolization in Management of Central Nervous System Tumours.

Preoperative embolization plays a significant role as an adjunct to surgical intervention in the cases of certain vascular tumours of the brain. While the procedure has resulted in facilitated resection of the tumour, and has reduced morbidity and mortality, its application remains debatable within the neurosurgical community, owing to rare, but major post-procedural complications. Herein, we have reviewed the literature to assess the safety and efficacy of preoperative angiographic embolization for brain tumours.

Prevalence of allergic fungal sinusitis among patients with nasal polyposis.

OBJECTIVE: To determine the frequency of allergic fungal sinusitis among patients with nasal polyps, and to compare Lund-Mackay scores of patients with and without allergic fungal sinusitis. METHODS: The cross-sectional longitudinal study was conducted at a tertiary healthcare centre in Karachi, Pakistan, from December 2016 to November 2018, and comprised patients with sinonasal polyposis undergoing surgery. The patients were categorised as having allergic fungal sinusitis when histopathology showed allergic mucin with fungal hyphae and culture was positive for fungal growth. Lund-Mackay scoring of each patient was noted and mean scores of allergic fungal sinusitis and non-allergic fungal sinusitis patients were compared. Data was analysed using SPSS 25. RESULTS: Of the 114 patients, 61(53.5%) were males. The overall mean age was 37.3±15.3 years. Of the total, 27(23.7%) patients had allergic fungal sinusitis. There was a significant relationship between asthma and allergic fungal sinusitis (p=0.03). The mean Lund-Mackay score was significantly higher for allergic fungal sinusitis patients (p<0.01). Recurrence was seen in 11(9.6%) cases. CONCLUSIONS: About one-fourth of patients with nasal polyps had allergic fungal sinusitis, and such patients showed significantly high mean Lund-Mackay score.

Role of multi-parametric (mp) MRI in prostate cancer.

Multi-parametric magnetic resonance imaging is increasingly being recommended as standard imaging modality for prostate cancer diagnosis and staging. It comprises structural T2 and T1 sequences supplemented by functional imaging techniques, i.e. diffusion-weighted, dynamic contrast enhanced and spectroscopic imaging. Pre-biopsy multi-parametric magnetic resonance imaging is recommended for both detection and staging as it avoids biopsy artefact, and when normal, has a negative predictive value of 95% for significant cancer. Magnetic resonance imaging-guided prostate biopsy targets only area(s) considered to be suspicious for prostate cancer, hence resulting in improved accuracy. Dynamic contrast enhancing helps in the detection of cancer and for the assessment of extra-capsular extension, distal urethral sphincter and seminal vesicles involvement. The role of multi-parametric magnetic resonance imaging in follow-up of patients on active surveillance is also increasingly recognised. Its role is now further expanded to facilitate targeted therapies. This review focuses on the evolving role of multi-parametric magnetic resonance imaging in diagnosis and management of prostate cancer.

Multiplanar imaging of inferior vena cava variants.

Inferior vena cava (IVC) variants are rare and are usually detected incidentally. Even though, these variants are by themselves asymptomatic, they can have important clinical, radiological, and surgical implications. In this pictorial essay, we sensitize the reader to various IVC variants by presenting reports of actual patients. A succinct description of the embryological development of these anatomic variants is also provided.

Comparison of microcoils and polyvinyl alcohol particles in selective microcatheter angioembolization of non variceal acute gastrointestinal hemorrhage.

OBJECTIVES: To compare the efficacy of polyvinyl alcohol (PVA) particles with microcoils in angiembolisation of non variceal acute gastrointestinal haemorrhage. METHODS: This is a retrospective cross-sectional study of patients who underwent transcatheter angioembolization from January, 1995 to December, 2013 at Aga Khan University Hospital, Karachi. Patients were divided into two groups on basis of use of either microcoils or PVA particles and compared in terms of technical success, clinical success, re-bleeding and ischemic complication rates. Chi (χ(2)) square and Fisher's exact tests were applied and a P-value of less than 0.05 was considered statistically significant. RESULTS: Fifty seven patients underwent angioembolization. Microcoil and PVA particles embolization was performed in 63% (36/57) and 35% (20/57) cases respectively. Technical success was achieved in all cases (100%). Clinical success rate was higher in microcoils group (92%) than PVA particles group (75%) with statistically significant P value (p=0.048). Ischemic complication was seen in one case (3%) in the microcoil group, while no such complications were seen in the PVA particles group. CONCLUSION: In angioembolization of non variceal acute gastrointestinal haemorrhage microcoils are better than Polyvinyl alcohol particles with higher clinical success and lower re-bleed rates.

Recurrent spontaneous splenic rupture in a patient with congenital factor XIII deficiency.

We describe an unusual presentation of factor XIII (FXIII) deficiency in a 17-year-old boy who was diagnosed with this congenital deficiency at the age of 18 months. He had a history of spontaneous splenic rupture 8 years ago, which was managed conservatively. He now presented with sudden severe abdominal and left shoulder pain for 1 day, with no history of antecedent trauma. He was in shock, and examination revealed diffuse peritonitis. A computed tomography scan showed a grade IV splenic laceration. He was taken as an emergency to the operating room where he was found to have a shattered spleen, and a splenectomy was performed. He received cryoprecipitate transfusions perioperatively. After an uneventful recovery, the patient was discharged. To the best of our knowledge, this is the first described case of a recurrent splenic rupture in a patient with FXIII deficiency.

Effectiveness of Haemophilus influenzae type b conjugate vaccine on radiologically-confirmed pneumonia in young children in Pakistan.

OBJECTIVE: The effectiveness of Haemophilus influenzae type b (Hib) vaccine in preventing severe pneumonia in Asian children has been questioned, and many large Asian countries yet to introduce Hib conjugate vaccine in immunization programs. The primary objective of this study was to assess Hib conjugate vaccine effectiveness (VE) on radiologically-confirmed pneumonia in children born after introduction of Hib conjugate vaccine in Pakistan. STUDY DESIGN: A matched case-control study enrolled cases of radiologically-confirmed pneumonia in several hospitals serving low-income populations during 2009-2011. Cases were matched by age and season with 3 hospital and 5 neighborhood controls. Pneumonia was diagnosed using standardized World Health Organization criteria for chest radiograph interpretation. Matched OR were estimated for VE. RESULTS: A total of 1027 children with radiologically-confirmed pneumonia were enrolled; 975 cases, 2925 hospital controls, and 4875 neighborhood controls were analyzed. The coverage for 3 doses of diphtheria-tetanus-pertussis-hepatitis B-Hib conjugate vaccine was 13.7%, 18%, and 22.7% in cases, hospital controls and neighborhood controls, respectively. Estimated Hib VE for radiologically-confirmed pneumonia was 62% with 3 doses of vaccine using hospital controls and 70% using neighborhood controls. CONCLUSIONS: Hib conjugate vaccine prevented a significant fraction of radiologically-confirmed pneumonia in children in Pakistan. Maximizing impact on child survival needs improved immunization coverage.

An institutional review of transarterial embolization in haemorrhagic urological emergencies.

OBJECTIVE: To review the effectiveness of therapeutic transarterial embolization in controlling phagic urological emergencies irrespective of the cause of emergencies. METHODS: Thirty-seven vascular angiographies were performed in 32 patients (19 males and 13 females, age range 19-70 years) who were referred with haemorrhagic urological emergencies to Aga Khan University Hospital's angiography suite from July 2005 to June 2010. Embolization was performed with coils, polyvinyl alcohol particles, N-Butyl cyanoacrylate glue and gel foam according to the clinical indication. Data on clinical indication, technique, site and type of bleeding lesions were obtained from a retrospective review of medical records. Success rate, clinical outcome and complications of the procedure were analysed. RESULTS: Indications of procedure included iatrogenic injury (16), Renal mass on clinical examination and imaging (4), haematuria with pseudoaneurysm on examination (3), haematuria with no known cause (3), post traumatic renovascular injury (2) Renal arteriovenous fistulas (2), Carcinoma of prostate (1) and pelvic arteriovenous (AV) fistula (1). Twenty four patients underwent successful endovascular control of bleeding. Eight examinations were negative for active extravasation, two of whom showed haemorrhage in second session and were embolized. Two sessions were needed in two patients at different time intervals. Complication as dislodgement of coil in distal profunda femoris artery was seen in one patient with no significant obstruction to flow. CONCLUSION: Transarterial renal angioembolisation is a safe and effective therapeutic tool for managing haematuria or haemorrhage in urological emergencies. Wherever and whenever indicated it should be the first preferred treatment modality.

Leaking pseudoaneurysm of hepatic artery: a potentially life-threatening complication of a common procedure.

We report a case of leaking pseudoaneurysm of right hepatic artery in a 54-year old female after laparoscopic cholecystectomy who presented with massive gastrointestinal haemorrhage and was successfully managed with angiography and coil embolization.

Transjugular intrahepatic portosystemic shunt (TIPS); review of initial experience at Aga Khan University Hospital.

OBJECTIVE: To retrospectively assess the therapeutic effectiveness and safety of transjugular intrahepafic portosystemic shunt (TIPS) in patients with portal hypertension related complications. METHODS: Over a period of 7.5 years 19 patients (10 males and 9 females, age range 25-69 years) were referred for TIPS at our radiology department. Thirteen patients suffered from liver cirrhosis while 6 had Budd Chiari syndrome. All patients were evaluated with colour doppler ultrasonography and cross sectional imaging. Shunt procedures were performed under sedation or general anaesthesia through internal jugular approach. Metallic self expandable uncovered stents were placed in 15 patients and covered stent in 1 patient. Follow up of patency was evaluated with ultrasound in majority and by venography in some patients. Safety of the procedure and clinical outcome were analyzed. RESULTS: Indications of procedure included variceal bleeding (n=8), ascites (n=4), ascites and bleeding (n=1) and Budd-Chiari syndrome (n=6). Technical success rate was 84.21%. Complication rate was 10.53%. Three days mortality was 15.79%. Mean primary shunt patency was 306.62 +/- 533 days. During follow-up stent occlusion occurred in 5 patients (31.25%). Four of these patients underwent successful reintervention. Recurrence of symptoms occurred in 68.75% patients. CONCLUSION: TIPS is useful for management of complications of portal hypertension that are refractory to pharmacological and endoscopic treatment, however shunt stenosis or occlusion may cause recurrence of symptoms. Repeated interventions are often required to maintain shunt patency.

Endovascular approach as primary treatment for traumatic carotid cavernous fistula: local experience from Pakistan.

OBJECTIVE: To evaluate the technical success, complications and outcome of endovascular management of post traumatic carotid cavernous fistula (CCF) in patients presenting at a tertiary care hospital in Karahci. METHODS: Descriptive case series of 26 patients of post traumatic CCF treated by endovascular techniques was carried out at Radiology and Neurosurgery departments of Aga Khan University hospital between January 2010 to March 2010. Medical records and radiology reports were retrospectively reviewed from November 2000 to December 2009. The diagnosis was primarily clinical and was confirmed in all cases by CT or MRI. Endovascular procedures were performed under general anaesthesia through femoral artery or femoral vein approach. Detachable balloons pushable coils and/or glue was used for fistula closure. Follow up was done via medical records and on phone. Technical success and safety of the procedure were analyzed and outcome in terms of symptomatic improvement was recorded wherever available. RESULTS: Out of a total of 26 patients; 20 were male and 6 were female, with age range of 14 to 62 years, mean age 31.4 +/- 12.6 years. Technical success rate of endovascular embolization was 92.3% (24 out of 26 patients). Procedure could not be performed in 2 patients. In 20 out of 24 patients (83.3%) single session of embolization was performed while 4 patients required 2 sessions due to recurrence. In one of these patients the detachable balloon deflated after 2 hours of deployment and another session of embolization was immediately carried out by deploying a larger sized balloon. Complication rate was 15.3% (n = 4) one patient had infarction which recovered completely in 6 months. There was no procedure related mortality. Five patients were lost to follow up. In rest of the 19 patients follow up ranged from 1 to 14 months (Mean 11.0 +/- 11.8 months) 8 out of 19 (42.1%) patients showed complete resolution of symptoms and 9 (47.3%) reported improvement. CONCLUSION: Endovascular approach is a safe and useful option for treatment of traumatic carotid cavernous fistula.

An Assessment of the Impact of Flow Disruptions on Mental Workload and Performance of Surgeons During Percutaneous Nephrolithotomy.

Objective The aim of this study was to assess the impact of intraoperative disruptions on surgeons' workload and performance during percutaneous nephrolithotomy (PCNL). Materials and methods A structured and standardized tool was used to identify disruptions and interferences that occurred during 33 PCNL procedures. The surgical steps during PCNL were divided into four phases: ureteric catheter placement (phase I), puncture and tract dilation (phase II), intra-calyceal navigation and stone fragmentation (phase III), and tube placement (phase IV). Surgeons' workload was evaluated using a validated tool: Surgery Task Load Index (SURG-TLX), and correlated with the mean observed intraoperative disruptions. All operating team members evaluated the teamwork immediately after the procedure. Statistical analysis was performed using SPSS Statistics version 22 (IBM, Armonk, NY). Results A total of 1,897 disturbances were observed, with an average of 57.48 ± 16.36 disruptions per case. The largest number of disruptions occurred during phase III of PCNL (32.06 ± 14.12). The most common cause of the disruption was people entering or exiting the operating room (OR) (29.1 ± 10.03/case), followed by the ringing of phones or pagers (6.42 ± 2.4). The mean observed intraoperative disruptions were significantly associated with the operating surgeon's mental workload, and it had a significant impact on all domains of surgeons' mental workload as measured by SURG-TLX. Compared to other team members, surgeons' assistants experienced an inferior sense of teamwork (r=-0.433; p=0.012). Conclusion Significant intraoperative disruptions were observed during PCNL. They were observed to directly correlate with the surgeon's workload and had a detrimental effect on teamwork. Improving OR dynamics by reducing unnecessary disruptions would help establish an efficient and smooth surgical work environment for safe surgical care.

Angioembolisation for the Treatment of Pseudo-aneurysm of Internal Maxillary Artery.

Pseudo-aneurysm of internal maxillary artery, following a road traffic accident, is a rare clinical scenario. The consequence of pseudo-aneurysm may be spontaneous rupture of the arterial wall, which may eventually lead to life-threatening hemorrhage. We report a case of a 20-year male who presented with recurrent epistaxis. CT scan was performed, which revealed a pseudo-aneurysm of the internal maxillary artery; this was successfully treated by angioembolisation. Similar cases of traumatic pseudo-aneurysms have been reported, however, none presented with recurrent epistaxis after management of pan-facial fractures. Key Words: Epistaxis, Pseudo-aneurysm, Angioembolisation, Pan-facial fracture.

Erratum to: Hepatocellular carcinoma with extrahepatic blood supply from right renal artery.

[This corrects the article DOI: 10.1093/jscr/rjab391.].

Treatment of intracranial aneurysms using detachable coils; initial results at a university hospital in Pakistan.

OBJECTIVE: To evaluate the technical success, safety and outcome of endovascular coiling procedure in intracranial aneurysms. METHODS: From April 2003 to April 2009, 43 patients (23 males and 20 females), age range 11 to 70 years, mean age 46.67 +/- 11.57 years were treated for intracranial aneurysms by detachable coil deployment at Radiology Department of Aga Khan University Hospital. Aneurysm rupture with subarachnoid haemorrhage was the cause of presentation in 39 patients while 4 patients were diagnosed with un-ruptured aneurysms. At time of presentation, grading of subarachnoid haemorrhage was done according to Hunt and Hess grading system. Eleven patients presented with Grade I haemorrhage, other 11 presented with grade II haemorrhage, 8 patients had grade III haemorrhage and 9 patients had grade IV haemorrhage. Preliminary diagnostic workup was performed by cross sectional imaging, CT angiography or digital substraction angiography. Coiling procedures were performed under general anaesthesia through femoral artery approach. Detachable platinum coils were densely packed in all aneurysms by endovascular technique. Patient files and radiology reports were retrospectively reviewed. Technical success and safety of the procedure were analyzed. Modified Rankin Score was used to determine clinical outcome. Score 0-2 represented good outcome, score 3-5: dependency (Can not attend own bodily needs and carry out daily activities without assistance) and score 6: death. RESULTS: Aneurysm size ranged from 3mm - 22mm (mean size 8 mm +/- 4). 74.4% aneurysms had narrow necks while 25.6% aneurysms were wide necked. Most common aneurysm site was anterior communicating artery. Technical success rate for endovascular intracranial aneurysm coiling was 95.3% (n = 41). Major complication rate was 11.6 % (n = 5). Mortality rate was 2.3% (n = 1). 78% patients showed good clinical outcome after coiling including 4 patients with un ruptured aneurysms (n = 32). CONCLUSION: Results of endovascular aneurysm coiling at our center showed high technical success rate (95.3%) and good short term clinical outcome in 78% patients.

The Correlation Between STONE Nephrolithometry Score and Hemoglobin Drop in Patients Undergoing Percutaneous Nephrolithotomy.

Objective In this study, we aimed to determine the correlation between the STONE score [(S)ize of the stone, (T)opography or location, degree of (O)bstruction of the urinary system, (N)umber of stones, and (E)valuation of Hounsfield units] and postoperative hemoglobin drop in patients undergoing percutaneous nephrolithotomy (PCNL). Methods This was a prospective observational study and all adult patients aged 18-65 years undergoing unilateral, single-tract PCNL using 26 Ch. Amplatz sheath for renal calculi were included. The five variables of the STONE nephrolithometry score were calculated prior to the procedure. The stone-free rates were assessed on imaging at four weeks and complications were graded using the modified Clavien system. Results Of the 142 patients included, 75% were below 55 years of age. More than half of our patients were diabetic with more than 60% having a body mass index (BMI) above 25 kg/m2. The mean STONE score was 7 with 33% having a high (>9) STONE score. The mean hemoglobin drop was 1.15 +0.92 g/dL with eight patients (5.63%) requiring transfusion and one (0.7%) requiring angioembolization; one patient required readmission for observation. Complete STONE clearance was achieved with PCNL alone in 78.2% of the patients. There was a significant correlation of hemoglobin drop with the STONE score, stone size, and preoperative creatinine clearance. Patients with a hemoglobin drop of >1 g/dL had a higher STONE score and mean stone size. The overall complication rate was significantly higher (10.5%) in patients with a hemoglobin drop of >1 g/dL as compared to those with a hemoglobin drop of <1 g/dL (2.8%). Conclusion Stone complexity as measured by the STONE score correlates with post-PCNL hemoglobin drop, stone clearance, and complication rates. The STONE score may be used for preoperative counseling and to evaluate the potential need for transfusion.

Validation of S.T.O.N.E nephrolithometry and Guy's stone score for predicting surgical outcome after percutaneous nephrolithotomy.

BACKGROUND: The aim of this study was to validate and compare Guy's and S.T.O.N.E. scoring systems in predicting perioperative and postoperative outcome following percutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS: From November 2015 to June 2017, 190 patients with renal stones who underwent single tract unilateral PCNL in the prone position were included in our study. Guy's and S.T.O.N.E. nephrolithometry scores were calculated in each case based on preoperative computed tomography images. The association of these scoring systems with stone-free status, length of hospital stay, operative time, and postoperative complications was studied. Regression analysis was done, and receiver operating characteristic curves were plotted. RESULTS: Mean S.T.O.N.E. and Guy's stone scores were 8.76 ± 2.29 and 2.70 ± 1.0, respectively. When compared with patients with residual stones, stone-free (SF) patients had significantly lower mean Guy's score (2.58 ± 1.01 vs. 3.23 ± 0.77 [P < 0.001]) and S.T.O.N.E. scores (8.44 ± 2.24 and 10.17 ± 2.0 [P < 0.001]), respectively. On logistic regression analysis, both Guy's score (odds ratio [OR] = 0.48, P = 0.001) and S.T.O.N.E score (OR = 0.78, P = 0.001) were found to be significantly associated with SF status. Both of these scoring systems were also significantly associated with longer operative time (>90 min), prolonged hospital stay (>3 days) and overall complications. No significant difference was found in the area under curve for both scoring systems for stone clearance. CONCLUSION: Both the S.T.O.N.E and Guy's scoring systems were found to predict the outcome of PCNL, either of these could be used in the routine clinical practice for patients' counseling.

Determination of complication rate of PICC lines in oncological patients.

OBJECTIVE: To determine the complication rate of (PICCs) peripherally inserted central catheters in cancer patients with a 1 year prospective cohort study. METHODS: All PICCs inserted in adult cancer patients in Radiology Department of The Aga Khan University Hospital were followed prospectively till removed or patient expired and pattern of complications noted. RESULTS: One hundred and fourty six PICCs were inserted over a period of 1 year and followed for a total of 3329 catheter-days; median placement, 14 days: range 3-218 days. Of these 67 (32.8%) PICCs were complicated and removed earlier, for a rate of 14.4/1000 PICC-days. Patients with haematologic malignancies were more likely to have complications as compared to those with solid tissue malignancies. CONCLUSIONS: Despite a significant complication rate, PICCs are a relatively safe and cost effective method of establishing central venous access.

Complications of Ultrasound-guided Liver Biopsy at a Tertiary Care Hospital in Pakistan: An Audit.

Introduction Liver diseases account for two million deaths per year worldwide, half of which are attributed to complications of cirrhosis. Liver conditions have wide-ranging serological findings and imaging appearances and may require biopsy for a definitive diagnosis. Despite ultrasound (US) guidance, liver biopsy is an invasive procedure and the expected benefit must outweigh risks involved.  Objective  The purpose of the audit was to calculate complication rates of US-guided liver biopsy and summarize institutional data pertaining to the procedure.  Materials and Methods The audit was performed at Aga Khan University Hospital, Karachi, Pakistan. All consecutive patients undergoing liver biopsy from February 2017 - February 2018 were included. Medical records of patients were reviewed for complications of liver biopsy.  Results The study population consisted of 157 adult and 21 pediatric patients. Complications were encountered in nine patients (5%), minor complications in seven (4%) and major complications in two (1.1%). Among the minor complications, haematoma formation was noted in four patients (2.2%), minor abdominal pain in two patients (1.1%), and minor hemorrhage during the procedure in one patient (0.5%). Minor complications were seen more frequently in pediatric (14%) patients as compared to adults (3.8%). One patient developed a major hemorrhage (> 2 g/dl drop in hemoglobin (Hb)), and another patient developed severe vasovagal hypotension. There was no mortality in the study population resulting from complications of the liver biopsy. The audit standards set were met for all parameters, except major hemorrhage (< 0.5%) which was narrowly missed (0.56%). Conclusion US-guided liver biopsy at our institution has a good safety profile with complication rates within the expected range. Departmental practices are compliant with established practices and guidelines.

Diagnostic Accuracy of Computed Tomography Scout Film and Chest X-ray for Detection of Rib Fractures in Patients with Chest Trauma: A Cross-sectional Study.

BACKGROUND: Rib fractures are a major source of morbidity in patients with chest trauma. Computed tomography (CT) scout film is a low-dose image that is obtained prior to a complete chest CT study for all patients undergoing a CT scan. In this study, we evaluated the diagnostic performance of CT scout film vis-à-vis that of chest X-ray for detection of rib fractures using chest CT scan as the reference standard. METHODS: A cross-sectional study was performed at the radiology department of Aga Khan University Hospital (Karachi, Pakistan) from October 1, 2013 to September 31, 2014. Patients who underwent CT chest for evaluation of thoracic trauma were included in the study. Sensitivity and specificity of chest X-ray and CT scout film were calculated. RESULTS: A total of 207 patients were included in the study (193 were male). Penetrating and blunt thoracic injuries affected 104 (50.2%) and 103 (49.8%) patients respectively. On CT chest, 75 (36.2%) patients had evidence of rib fractures. Sensitivity and specificity of CT scout film for detection of rib fractures were 56% and 87.9%, while those of chest X-ray were 61.3% and 98.5% respectively. The overall accuracy of CT scout film and chest X-ray for detection of rib fractures were 76.3% and 85% respectively. CONCLUSION: Diagnostic performance of CT scout film for detection of rib fractures was comparable to that of the plain chest radiograph. CT scout film does not provide any additional information or advantage over a plain chest radiograph. In patients with severe thoracic trauma, CT chest remains the modality of choice for accurate delineation of rib fractures and associated internal injuries.