Anti-programmed-death-receptor-1 (PD-1) antibody (Pembrolizumab) induced pancreatitis diagnosed on 18F-FDG PET/CT.

Immunotherapy related adverse events are commonly seen with immune check point inhibitors therapy. We report the case of a 40-year-old female diagnosed with stage IVB endometroid grade III endometrial cancer, on pembrolizumab immunotherapy, an anti-programmed-death-receptor-1 (PD-1) antibody. Patient was referred for 18F-FDG PET/CT for restaging. 18F-FDG PET/CT demonstrated diffuse increased FDG uptake throughout the body of the pancreas associated with fat stranding in the peripancreatic region, suggestive of pembrolizumab-induced pancreatitis. The diagnosis was confirmed by elevated amylase and lipase levels. immune-related adverse events (irAE) are frequently identified on 18F-FDG PET-CT, which may lead to early diagnosis, close clinical follow-up, and appropriate clinical management of immune-related adverse events.

To determine the efficacy of bilateral inferior petrosal sinus sampling in differentiating Cushing disease from ectopic Cushing syndrome.

Management of endogenous Cushing syndrome is based on its aetiology. Increased Adrenocorticotropic Hormone (ACTH) levels are the most common cause of this disorder and, therefore, it is critical to determine the source of ACTH before further management. Dynamic post contrast MRI is currently the most common investigation implied to diagnose pituitary adenoma; however, it comes with the drawback of low specificity and high false positive results. Inferior petrosal sinus sampling (IPSS) is an established invasive procedure performed to differentiate central versus peripheral source of ACTH which, in turn, results in hypercortesolaemia. This is a series of 14 patients who underwent IPSS at the Department of Radiology, Aga Khan University Hospital, Karachi, from January 2006 to December 2018. The case series emphasises the role of IPSS in the management of ACTH-dependent Cushing syndrome and combined efficacy of Dynamic post-contrast MRI and the procedure under focus.

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.

Challenges in diagnosis of disease reported 100 years back: Cushing syndrome; recent advances.

Treatment of Cushing syndrome depends on diagnosis of etiology responsible for hypercortisolism in the body, which sometimes presents with a challenge. Inferior petrosal sinus sampling for ACTH levels, followed by peripheral venous sampling is a proven tool to be a gold standard for differentiating between peripheral and central cause of ACTH dependent Cushing syndrome. This case report is of an elderly female who presented as an outpatient in the endocrinology clinic of Aga Khan university hospital on 22/6/2017 with clinical features of hypercortisolism. After workup she was found to have cushing syndrome secondary to ACTH secreting bronchial carcinoid tumour.

To identify the features differentiating peritoneal tuberculosis from carcinomatosis on CT scan abdomen taking omental biopsy as a gold standard.

OBJECTIVE: To differentiate peritoneal tuberculosis from carcinomatosis on computed tomography scan of abdomen, taking omental biopsy as the gold standard.. METHODS: This retrospective diagnostic accuracy review of cases was conducted at Aga Khan University Hospital, Karachi, and comprised patient's medical record files from February 2007 to February 2016. Computed tomography scan findings were compared with diagnosis made on the basis of histopathology. Multiple logistics regression analysis was done and sensitivity and specificity were tested through Pearson chi square test. RESULTS: Of the 98 patients identified, 62(63.2%)were found to be cases of disseminated tuberculosis and 36(36.7%) were diagnosed as malignant on histopathology. Computed tomography features were significantly specific to differentiate abdominal tuberculosis from carcinomatosis (p=0.004). On computed tomography,4 findings showed statistical significance: Smooth thickening of the peritoneum (p<0.001), abdominal mass (p=0.03), lymph node necrosis (p=0.024) and high-density ascitic fluid (p<0.001). Out of these, smooth thickening of the peritoneum (sensitivity=77%; specificity=86.1%) and high-density ascitic fluid (sensitivity=68.9%; specificity=72.2%) were more specific findings. Overall, the sensitivity and specificity of computed tomography was found to be 88.5% and 83.3%, respectively. CONCLUSIONS: Although no single finding on a computed tomography scan was diagnostic proof of peritoneal tuberculosis, a combination of findings could reliably distinguish between peritoneal tuberculosis and carcinomatosis. .

Varied percutaneous and endovascular management of large iatrogenic Profunda Femoris artery pseudoaneurysm.

The case of an elderly male diagnosed with a large iatrogenic pseudoaneurysm arising from the profunda femoris artery on ultrasound examination is presented. The immediate postoperative period was uneventful; however later he developed leg swelling and mild oozing at the incision site. In view of deranged renal function CT angiogram was not done and decision was made to treat the pseudoaneurysm with percutaneous thrombin injection. Almost complete thrombosis was achieved however a small residual portion remained patent near the neck. Later limited contrast angiography was done which re-demonstrated a small anneurysm. Instead of embolizing the vessel completely repeat prolonged balloon inflation was done which later showed no further filling of the pseudoaneurysm.

Peripherally Inserted Central Venous Catheters in Pediatric Hematology/Oncology Patients in Tertiary Care Setting: A Developing Country Experience.

PURPOSE: Peripherally inserted central venous catheters (PICC) have been successfully used to provide central access for chemotherapy and frequent transfusions. The purpose of this study was to assess the feasibility of PICCs and determine PICC-related complications in pediatric hematology/oncology patients in a resource-poor setting. METHODS: All pediatric patients (age below 16 y) with hematologic and malignant disorders who underwent PICC line insertion at Aga Khan University Hospital from January 2008 to June 2010 were enrolled in the study. Demographic features, primary diagnosis, catheter days, complications, and reasons for removal of device were recorded. RESULTS: Total of 36 PICC lines were inserted in 32 pediatric patients. Complication rate of 5.29/1000 catheter days was recorded. Our study showed comparable complication profile such as infection rate, occlusion, breakage, and dislodgement. The median catheter life was found to be 69 days. CONCLUSIONS: We conclude that PICC lines are feasible in a resource-poor setting and recommend its use for chemotherapy administration and prolonged venous access.

An Unusual Presentation of Choriocarcinoma in a Postmenopausal Woman: A case report.

Choriocarcinoma (CC) is a malignant neoplasm of the trophoblastic tissue, with a potential to metastasise to distant organs. Limited case of gestational CC develops after a long latent period. We report a 52-year-old postmenopausal woman who developed metastatic choriocarcinoma presumably of gestational origin, 8 years after the last pregnancy and 2 years after the last menstrual period. The patient was brought to the emergency room of a tertiary care centre in Muscat, Oman, in 2022 and was diagnosed with CC metastatic to the brain, spleen, lung and the kidney. The ß-human chorionic gonadotrophin level was found to be raised (1,292,867 mIU/mL). The International Federation of Gynecologic Oncology risk score was calculated to be 14 (very high risk). The patient was initially treated with whole-brain radiotherapy and splenic artery embolisation because of a hemoperitoneum. Afterwards the patient received systemic treatment using the standard EMA/CO regimen till complete serological remission.

Acquired Uterine Vascular Anomaly: Experience from a tertiary care centre in Pakistan.

Objectives: This study aimed to retrospectively review imaging findings and the outcomes of uterine artery embolisation (UAE) in symptomatic uterine vascular anomalies (UVA). Methods: This study included a total of 15 patients with acquired UVA admitted to the Aga Khan University Hospital in Karachi, Pakistan, from 2010 to 2020. These patients were evaluated using ultrasound, computed tomography and magnetic resonance imaging, either alone or in combination. All patients had a history of dilatation and curettage or uterine instrumentation and underwent angiography and embolisation of the uterine arteries. The primary outcome post embolisation was assessed clinically and/or in combination with ultrasound. Post-procedure pregnancies were also recorded. Results: Non-invasive imaging was abnormal in all patients; however, this pre-intervention imaging was unable to accurately classify the type of vascular anomaly, except in the case of a pseudoaneurysm. Conventional angiography showed uterine artery hyperaemia in six patients, arteriovenous malformation in seven patients and pseudoaneurysm in two patients. The technical success rate was 100% and no repeat embolisation was needed. The follow-up ultrasound in 12 patients revealed a resolution of the abnormal findings, while the remaining three were found to be normal on clinical follow-up. Seven patients (46.7%) had a normal pregnancy 15.7 months after the procedure (range: 4-28 months). Conclusions: UAE is a safe and effective management option for intractable severe bleeding in patients with UVA post instrumentation and it was found that the procedure does not impair future pregnancy.

Rare co-occurrence of dural arteriovenous fistula and arteriovenous malformation with bilateral subcortical and basal ganglia calcification.

The present study describes the imaging findings in a patient with dural arteriovenous fistula (AVR) and arteriovenous malformation (AVM) with bilateral subcortical and basal ganglia calcification. A 29 year old male patient presented with chief complaint of recent onset of generalized tonic clonic seizures and mild disorientation. The imaging studies on MCT demonstrated diffuse, symmetric calcification in the bilateral basal ganglia and subcortical white matter. MR imaging and angiography revealed AVM in parietooccipital region with supply predominantly from left posterior cerebral and middle cerebral arteries. Multiple dural feeders from meningeal branches of occipital and superficial temporal branches of bilateral external carotid and right internal carotid arteries. Calcification is proposed to be due to chronic reflux into the parenchymal veins or vascular steal phenomenon. This rare co-occurrence of subcortical calcification in a patient with a dural AVF and AVM is being reported.

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.

Percutaneous endovascular removal of a broken port-a-catheter from right atrium using manual made snare.

Fracture and migration of port-a-catheter, following long term access into the central venous vasculature is a rare clinical scenario. The consequences of fracture and migration includes fragmented device relocating into the right atrium or ventricle, eventually causing life threatening complications such as arrhythmias, pseudoaneurysms, perforations or very rarely embolization. We report a case of a 67-year-old female with a broken port-a-catheter which had been placed initially for chemotherapy for bilateral breast cancer. Chest radiograph showed the fragmented catheter had migrated to the right atrium; which was successfully removed via percutaneous radiological endovascular intervention. No immediate post procedure complication was noted.

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.

Angiography and Therapeutic Embolisation of Bleeding Aberrant Iliac Artery Branches.

A 78-year female presented with the complain of per rectal fresh bleeding for 4 days. She was known to have diabetes and hypertension, 3 weeks back. She had an episode of left middle cerebral artery (MCA) stroke. After stroke, she suffered from upper limb weakness and aphasia. At the time of presentation, her vitals showed blood pressure of 118/52 mmHg, O2 saturation of 98%, temperature: 37°C, respiratory rate (RR) of 20/min, and heart rate (HR) of 90 bpm. After achieving hemodynamic stability, she was transferred to radiology department. Her presenting complain of active rectal bleeding was managed by interventional radiologist using angiographic embolisation. In this patient, it was found pooling of blood in a retrograde fashion in the sigmoid colon. Bleeding was initially believed to be coming from sigmoid arteries seen on images of CT scan and colonoscopy. However, arteriography showed that source of bleeding was from middle and inferior rectal arteries that originated from left internal iliac artery. The intervention radiology (IR) team had to put in extensive effort to locate and perform therapeutic embolisation.

Frequency of Severity of Disability in Patients with Grade III Lumbar Neural Foraminal Stenosis on Magnetic Resonance Imaging.

Background Low back pain is a common condition and carries substantial socioeconomic implications. Magnetic resonance imaging (MRI) is the imaging modality of choice with lumbar neural foraminal stenosis being one of the most common causes of lower back pain syndromes. Studies have shown a lack of correlation between patients' severity of disability and radiologically determined nerve root constriction. Therefore, the goal of this study will be to determine the frequency of severity of disability in patients with severe (i.e., grade III) lumbar neural foraminal stenosis on MRI to ascertain the impact of MRI diagnosis on clinical outcomes. Materials and methods Two hundred fifty patients of either gender with a history of backache referred for MRI were included by purposive sampling. Of these 250 patients, 27 patients had grade II lumbar neural foraminal stenosis, and 21 had grade I neural foraminal stenosis on MRI and were excluded. Thirty-two patients had a spinal infection (e.g., tuberculosis), and 24 patients had a history of trauma. Further, 31 patients were having follow-up scans for previously diagnosed lumbar neural foraminal stenosis. Hence, after excluding these cases, 115 patients were enrolled in this cross-sectional study with grade III lumbar neural foraminal stenosis on MRI. Results The mean age was 51 years (range: 20 to 82 years). Most of the patients (55.6%) were older than 50 years. The most common site of grade III lumbar neural foraminal stenosis was L4-L5 (56.5%). According to the Oswestry disability index, 47 patients (40.9%) had a severe disability, 32 (27.8%) had a moderate disability, 16 (13.9%) were diabled, 14 (12.2%) had a mild disability, and six (5.2%) were bedridden. Conclusions While MRI is the imaging modality of choice in degenerative lumbar spinal stenosis, clinical disabilities can be more extensive than what radiological findings may indicate in approximately 40% of the cases. Therefore, lumbar spinal stenosis should be a neuro-radiological diagnosis, and surgical decisions should be based on clinical scenarios in addition to MRI findings.

Use of Interventional Radiology in Critically Injured Children Admitted in a Pediatric Intensive Care Unit of a Developing Country.

Objective The aim of this study was to describe the outcome of the use of interventional radiological procedures (IRP) (angioembolization) in critically injured children. Methods A retrospective review of medical records of all children who underwent an IRP from January 2010 to December 2015 was done. Data were collected on a structured proforma and results are presented as mean with standard deviation and frequency with percentages. Result Eighteen patients were identified who underwent IRP during the study period. The mean age was 10.4 ± 4.3 years and 10 (55%) were males. Ten patients had a road traffic accident, four had a history of fall, one patient had glass cut pelvic injury, and two patients had blunt abdominal trauma, while one patient had bleeding secondary to hemipelvectomy. The genitourinary system was involved in five patients, liver in four, and spleen in two and pancreas in one patient. Bleeding was from branches of internal iliac artery in seven patients, hepatic artery in three patients, splenic artery in two patients, and middle colic artery in one patient, while one patient had blood oozing from the bone after hemi-pelvictomy. Four French vascular access sheath was placed under ultrasound guidance; this was followed by the placement of C1 catheter (Cordis, Miami, FL). After vessel identification, a 2.7F Progreat microcatheter (Terumo, Tokyo) was used for super-selective cannulation of the bleeding vessel. Intravascular coil, polyvinyl alcohol (PVA) particles, or gel foam was used for the embolization of bleeding vessels. No procedural complications were observed except minor oozing in one patient. One patient expired due to multiorgan dysfunction. Conclusion Angioembolization is a useful and relatively safe procedure in the management of vitally stable children with hemorrhagic abdominopelvic injuries. However, further studies may be needed to evaluate the efficacy and cost-effectiveness of this practice, especially in resource-constrained settings.

Empiric Transcatheter Arterial Embolization for Massive or Recurrent Gastrointestinal Bleeding: Ten-year Experience from a Single Tertiary Care Center.

Purpose In patients with massive or recurrent gastrointestinal bleeding (GIB) which is not amenable to endoscopic therapy, angiographic interventions are often employed. We report our ten-year experience of empiric transcatheter arterial embolization (TAE) for patients with massive or recurrent GIB. Methods All patients who had undergone empiric TAE at our hospital between March 2004 and June 2015 were identified using the institutional radiology information system. A retrospective chart review was performed using a structured pro forma. Technical success rate, 30-day clinical success rate, 30-day mortality rate, and rate of procedural complications were computed. Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 20. Results A total of 32 patients had undergone empiric TAE for GIB during the study period. The median age of subjects was 56 years and two-thirds of them were male (68.7%). Gastroduodenal (n=24), ileocolic (n=3), left gastric (n=2), right gastroepiploic (n=1), and branches of superior and middle rectal arteries (n=1) were embolized using microcoils (n=25), polyvinyl alcohol particles (n=25), and gelatin sponge (n=3)--either alone or in combination. Technical and 30-day clinical success rates were 96.9% (31/32) and 71.9% (23/32), respectively. The 30-day mortality rate for our cohort was 21.9% (7/32). One patient developed re-bleeding at two days after the initial procedure and required repeat embolization. Coil migration (n=3) and access site hematoma (n=1) were the observed procedural complications. Conclusion Empiric TAE can be a useful treatment option for selected patients with massive or recurrent GIB that is not amenable to endoscopic therapy.

Neuroimaging Findings in Tuberculosis: A Single-Center Experience in 559 Cases.

BACKGROUND AND PURPOSE: There is a paucity of literature related to the neuroimaging of CNS tuberculosis (TB) and largely covers pediatric CNS TB. The objective of this study was to determine the frequency of different forms of CNS TB and its associated complications and to study longitudinal disease course using computed tomography (CT) and MRI. METHODS: Retrospective chart and imaging review of patients diagnosed with CNS TB in a tertiary care hospital in Pakistan over a 10-year period. A total of 452 initial brain MRI and 209 CT scans were reviewed by an expert radiologist specialized in neuroimaging. This was followed by review of 53 MRI/52 CT and 7 MRI/14 CT first and second follow-up scans, respectively. RESULTS: Note that 559 patients, 296 males and 263 females were included in the study. On the initial CT scans, tuberculomas were found in 25 (12%), infarction in 54 (25%), basal meningeal enhancement in 29 (14%), and hydrocephalus in 84 (40%). On initial MRI, tuberculomas were found in 182 (40%), infarction in 120 (27%), basal meningeal enhancement in 184 (41%), and hydrocephalus in 116 (26%). On review of follow-up CT scans, 13 (25%) showed new or worsening hydrocephalus, 8 (15%) showed new infarcts, 1 exhibited new tuberculoma, and 5 showed worsening cerebral edema. On review of follow-up MRI scans, new or worsening hydrocephalus was seen in 3 (6%), new infarcts in 3 (6%), new tuberculoma in 10 (19%), worsening cerebral edema in 7 (13%), and TB myelitis in 4 (8%) patients. CONCLUSIONS: Tuberculoma, hydrocephalus, and cerebral infarcts are the most prominent findings in CNS tuberculosis. Our study showed development of new lesions on subsequent neuroimaging suggesting a dynamic and progressive nature of the disease process in some individuals.

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.