Post traumatic avulsion of lumbar artery: a rare cause of retroperitoneal haemorrhage treated by glue embolization

Lumbar arterial injury after trauma is a rare cause of significant retroperitoneal haemorrhage. Early diagnosis followed by endovascular transcatheter embolization is a very effective treatment to control bleeding in patients who do not respond to conservative management. We present a case of post traumatic avulsion of left fourth lumbar artery which was successfully treated with percutaneous transcatheter arterial embolization with glue

Functional evaluation of the urinary tract by duplex Doppler ultrasonography in patients with acute renal colic

Purpose: To determine the role of duplex Doppler ultrasonography (DDU) in Patients with acute unilateral renal obstruction. Subjects And Methods:A total of 161 Patients with suspected renal colic due to urolithiasis were evaluated by DDU followed by intravenous urography (IVU). The mean intra-arterial resistive index (RI) and the difference of mean resistive index between both kidneys (delta RI) were determined for each person. An RI value of ≥0.70 and a delta RI value of ≥0.06 were taken as the discriminatory threshold for obstruction. IVU results were considered the reference standard against which renal DDU findings were compared. Results: IVU showed both kidneys to be normal in 51 Patients and with unilateral ureteric obstruction in 110 Patients. The mean RI for obstructed kidneys was 0.67 (0.048), which was significantly higher (P-value Conclusion: Delta RI is more sensitive and specific than RI in acute renal obstruction. However, due to relatively low sensitivity for detection of partial obstruction, DDU cannot replace IVU as the standard imaging technique

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\u27s 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

Inter-observer variability in diagnosing radiological features of aneurysmal subarachnoid hemorrhage; a preliminary single centre study comparing observers from different specialties and levels of training

BACKGROUND: A noncontrast computed tomography (CT) scan remains the initial radiological investigation of choice for a patient with suspected aneurysmal subarachnoid hemorrhage (aSAH). This initial scan may be used to derive key information about the underlying aneurysm which may aid in further management. The interpretation, however, is subject to the skill and experience of the interpreting individual. The authors here evaluate the interpretation of such CT scans by different individuals at different levels of training, and in two different specialties (Radiology and Neurosurgery). METHODS: Initial nonontrast CT scan of 35 patients with aSAH was evaluated independently by four different observers. The observers selected for the study included two from Radiology and two from Neurosurgery at different levels of training; a resident currently in mid training and a resident who had recently graduated from training of each specialty. Measured variables included interpreter's suspicion of presence of subarachnoid blood, side of the subarachnoid hemorrhage, location of the aneurysm, the aneurysm's proximity to vessel bifurcation, number of aneurysm(s), contour of aneurysm(s), presence of intraventricular hemorrhage (IVH), intracerebral hemorrhage (ICH), infarction, hydrocephalus and midline shift. To determine the inter-observer variability (IOV), weighted kappa values were calculated. RESULTS: There was moderate agreement on most of the CT scan findings among all observers. Substantial agreement was found amongst all observers for hydrocephalus, IVH, and ICH. Lowest agreement rates were seen in the location of aneurysm being supra or infra tentorial. There were, however, some noteworthy exceptions. There was substantial to almost perfect agreement between the radiology graduate and radiology resident on most CT findings. The lowest agreement was found between the neurosurgery graduate and the radiology graduate. CONCLUSION: Our study suggests that although agreements were seen in the interpretation of some of the radiological features of aSAH, there is still considerable IOV in the interpretation of most features among physicians belonging to different levels of training and different specialties. Whether these might affect management or outcome is unclear

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

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

Investor’s Dilemma: Fundamentals or Biasness in Investment Decision

In the present world Investment decision is most important phenomena. Investment is current sacrifice for future benefits, So while making investment decisions we have to keep different things in mind. Investment decisions are influenced not only by their fundamentals but also depend on different factors. One factor is the biasness of any investor to their investment, biasness depends on the cognition and emotions, because some investors use them as heuristic for the investment decision instead of fundamentals. Keeping this in view, this paper shows how cognitive biasness (i.e. Representativeness, Adjustment and Anchoring, Leniency) effects the investment decisions over the fundamentals. This study also show different types of investors which depicts significant relation of Representativeness, Adjustment and Anchoring, Leniency with investment decisions over fundamentals, and explain under which biasness an investor become more optimistic and moderate for investment decisions. While considering Representativeness biasness over fundamentals investor become more optimistic, In Adjustment and Anchoring biasness investor show moderate behavior about investment decision, and In Leniency biasness investor also take investment decision over optimistically

Endovascular embolisation of visceral artery pseudoaneurysms

Objective. To evaluate the technical success, safety, and outcome of endovascular embolization procedure in management of visceral artery pseudoaneurysms. Materials and Methods. 46 patients were treated for 53 visceral pseudoaneurysms at our institution. Preliminary diagnostic workup in all cases was performed by contrast enhanced abdominal CT scan and/or duplex ultrasound. In all patients, embolization was performed as per the standard departmental protocol. For data collection, medical records and radiology reports of all patients were retrospectively reviewed. Technical success, safety, and outcome of the procedure were analyzed. Results. Out of 46 patients, 13 were females and 33 were males. Mean patient age was 44.79 ± 13.9 years and mean pseudoaneurysm size was 35 ± 19.5mm. Technical success rate for endovascular visceral pseudoaneurysm coiling was 93.47% (n = 43). Complication rate was 6.52% (n = 3). Followup was done for a mean duration of 21 ± 1.6 months (0.5-69 months). Complete resolution of symptoms or improvement in clinical condition was seen in 36 patients (80%) out of those 45 in whom procedure was technically successful. Conclusion. Results of embolization of visceral artery pseudoaneurysms with coils at our center showed high success rate and good short term outcome

Observer variation in MRI evaluation of patients with suspected lumbar disc herniation and nerve root compression: Comparison of neuroradiologist and neurosurgeon\u27s interpretations

Objective: To analyse inter-observer variation between a neuroradiologist and neurosurgeon in the MRI diagnosis of lumbar nerve root compression. Although lumbar MFI is primarily analyzed and reported by a radiologist, neurosurgeons often analyse it independently as they have sufficient clinical background as well as radiological expertise to diagnose most spinal pathologies on Magnetic Resonance Imaging (MRI).Methods: Retrospective analysis was carried out for images of 54 patients who underwent MRI between March and July 2010 of lumbar spine with suspected lumbar disc herniation and nerve root compression, at Aga Khan Hospital, Karachi, Pakistan. One fellowship trained neuroradiologist and one neurosurgeon evaluated the images on PACS system separately. Both observers were unaware of the patient\u27s clinical history and each other\u27s findings. Lumbar discs at L3-L4, L4-L5 and L5-S1 levels were evaluated by both observers for disc disease and nerve compression. Findings were recorded on a proforma and analysed with SPPS Version 16.Results: Total 162 lumbar discs were studied by both readers in 54 patients. Excellent inter-observer agreement was seen for the presence or absence of nerve root compression (Percentage agreement = 88.89%; k = 0.774; p = 0.737). For disc bulge, inter-observer agreement was fair but statistically insignificant (Percentage agreement = 72.84%; k = 0.414; p = 0.132). In case of disc herniation, although inter-observer agreement was fair, but the difference was statistically significant (Percentage agreement = 84.57%; k = 0.511; p = 0.002).Conclusion: Inter-observer agreement between neuroradiologist and neurosurgeon in diagnosing nerve root compression due to lumbar disc disease was excellent. Agreement regarding disc bulge and herniation was fair