Losartan associated anaphylaxis and angioneurotic oedema

A case of anaphylaxis and angioedema induced by angiotensin II receptor blocker (ARB), losartan is reported. A 37 years old hypertensive female presented to the Emergency Department with swelling over the face especially the lips, urticarial rash all over the body, and dyspnoea within an hour of losartan administration. She did not have any previous history of drug allergies. The patient was managed with epinephrine. Although angioneurotic oedema and anaphylaxis are well documented adverse effects of angiotensin converting enzyme (ACE) inhibitors, very few cases of these adverse reactions with ARBs have been reported in medical literature

Suicide bombing: a geopolitical perspective

Suicide bombing is a very complex phenomenon. It has been a focus of research in recent times. However inherent biases of researchers muddle the picture: researchers from western countries focus the issue around political liberty and notion of democracy, while those from Islamic countries tend to take the afterlife-reward notion as an incentive for suicide bombing. However in order to understand this complex phenomenon it is important to consider the contextual factors. In this review we have attempted to highlight various geopolitical factors which contribute to increased incidence of suicide bombing in South East Asia

Intracranial cavernous angiomas

Objective: To describe the clinical presentation, diagnosis, and management of patients presenting with intracranial cavernous angiomas (CAs) at a tertiary care hospital in Pakistan.Study Design: Case series. Place and Duration of Study: Section of Neurosurgery, The Aga Khan University Hospital (AKUH), Karachi, from January 1990 to September 2008.Methodology: A retrospective case note review of all patients diagnosed with intracranial CAs at AKUH during the study period. The studied variables included patient demographics, clinical presentation, family history of intracranial CAs or other space occupying lesions, modality of diagnosis, management, and outcome. Results were described as frequency percentages.Results: During the review period, 18 patients (11 males and 7 females) were diagnosed with intracranial CAs. The median age at diagnosis was 28.5 years. The most common location of malformations was cerebrum (n=13) followed by brain stem (n=3), and cerebellum (n=2). Nine patients had multiple lesions. Family history was present in 2 patients. Seizures and focal neurologic deficits were the main clinical manifestations. The detection rate was 93.8% with magnetic resonance imaging, but less with angiography and computerized tomography. Ten cases were treated surgically; 8 were managed conservatively. The outcome was satisfactory except for one patient, who died within 6 months of diagnosis. Surgery was performed for gross haemorrhage, rapidly increasing neurologic deficits, and intractable or long-standing seizures.Conclusion: Cavernomas tend to occur at younger age in females than males. This data raises a possibility of a higher frequency of multiple cavernomas in Pakistani patients. The main clinical manifestations are seizures and focal neurologic deficits. MRI is most sensitive and specific neuroradiologic modality for detecting this vascular malformation

Delayed surgical therapy reduces mortality in patients with acute necrotizing pancreatitis

Objective: To review the trends in management and analyze the factors influencing outcomes of acute necrotizing pancreatitis.Methods: It wa a retrospective analytical study. All adult patients with computed tomography with proven necrotizing pancreatitis managed at the department of surgery, Aga Khan University Hospital, Karachi were included in this study extending from January 1998 to January 2008. Outcome variables were hospital stay, complication rate and in-hospital mortality. Data analysis was carried out using SPSS version 16. For comparison, Pearson chi-square test, Fisher\u27s exact test, t-test and ANOVA were used, where applicable. A p-value less than 0.05 was considered statistically significant. Results: Of 1479 patients, 47 patients were included. Median age was 48 (range: 38-56) years with 31(66%) males and 16(34%) females. Overall out of 18(38%) that underwent necrosectomy, 16 had infected acute necrotizing pancreatitis while the rest were negative. Computed Tomography and/or FNAC identified 18 infective acute necrotizing pancreatitis patients, 16 underwent necrosectomy, one patient expired without surgery and the other was managed conservatively. Enteral nutrition was widely used with rising trend of oral feeding from 2006 onwards. Complication rate was 63%. Overall mortality remained 9/47(19.7%), where in infected ANP as well as in postoperative patients, mortality was 7/18 (38.9%). The patients with early pancreatic necrosectomy had prolonged hospital stay, more complications and statistically significant increase in in-hospital mortality. Conclusion: Better outcomes were achieved in infected acute necrotizing pancreatitis with delayed pancreatic necrosectomy and the other contributing factor could be early enteral nutritional therapy

Microsurgical excisions of vestibular schwannomas: A tumor-size-based analysis of neurological outcomes and surgical complications

Introduction: Vestibular schwannomas (VS) are benign tumors originating from Schwann cells in vestibulocochlear nerve. This study aimed at evaluating outcomes of microsurgical resections of VS based on tumor sizes in a South Asian country.Methods: The chart notes of 71 Patients who underwent microsurgical resections of VS at a single academic center over a 20-year period (1990-2009) were reviewed, and relevant information was extracted. For analyzing outcomes, Patients were divided into two groups based on tumor size at initial presentation: (1) Group A (tumor size ≤ 4 cm) and (2) Group B (tumor size \u3e 4 cm). Pearson\u27s chi-square and Fisher\u27s exact tests were used for comparison of proportions, the independent sample t-test was used for comparison of means.Results: The average tumor diameter was 4.1 1.5 (range, 1-6.6) cm. Complete resection was achieved more frequently in Patients in Group A (P \u3c 0.001). Duration of hospital stay and cost of treatment were significantly higher in Group B Patients (P \u3c 0.003 and P \u3c 0.04, respectively). The severity of postoperative facial nerve injury, assessed by House-Brackmann grading system, was significantly higher in Group B (P \u3c 0.01). Cerebrospinal fluid (CSF) leak and lower cranial nerve deficits also occurred more frequently after resection in Group B (P = 0.031 and P = 0.003, respectively).Conclusion: We conclude that advanced stage tumors suggestive of delayed presentation are fairly common in Pakistan, and limit curative resection in the majority of Patients. Postoperative morbidity is significantly higher in Patients with tumor size \u3e 4 cm

Management of penetrating brain injury

Penetrating brain injury (PBI), though less prevalent than closed head trauma, carries a worse prognosis. The publication of Guidelines for the Management of Penetrating Brain Injury in 2001, attempted to standardize the management of PBI. This paper provides a precise and updated account of the medical and surgical management of these unique injuries which still present a significant challenge to practicing neurosurgeons worldwide. The management algorithms presented in this document are based on Guidelines for the Management of Penetrating Brain Injury and the recommendations are from literature published after 2001. Optimum management of PBI requires adequate comprehension of mechanism and pathophysiology of injury. Based on current evidence, we recommend computed tomography scanning as the neuroradiologic modality of choice for PBI Patients. Cerebral angiography is recommended in Patients with PBI, where there is a high suspicion of vascular injury. It is still debatable whether craniectomy or craniotomy is the best approach in PBI Patients. The recent trend is toward a less aggressive debridement of deep-seated bone and missile fragments and a more aggressive antibiotic prophylaxis in an effort to improve outcomes. Cerebrospinal fluid (CSF) leaks are common in PBI Patients and surgical correction is recommended for those which do not close spontaneously or are refractory to CSF diversion through a ventricular or lumbar drain. The risk of post-traumatic epilepsy after PBI is high, and therefore, the use of prophylactic anticonvulsants is recommended. Advanced age, suicide attempts, associated coagulopathy, Glasgow coma scale score of 3 with bilaterally fixed and dilated pupils, and high initial intracranial pressure have been correlated with worse outcomes in PBI Patients

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

Awareness of stroke risk factors, signs and treatment in a Pakistani population

OBJECTIVE: To assess the level of awareness in the general public on risk factors, symptomatology and immediate treatment of stroke.METHOD: A cross sectional study was conducted in a sample of subjects visiting a tertiary care university hospital by means of a self-designed questionnaire. The study period extended between May and June, 2007.RESULTS: A total of 398 individuals were surveyed. Hypertension (69.1%) and stress (55.8%) were identified as two major risk factors for stroke. Among them 50.8% identified Brain as the principal organ involved in stroke out of which 78.2% of the response came from people whose level of education was intermediate-and-above. Around 13% of the study respondents did not know of any risk factor for stroke, while 11.6% of the study respondents didn\u27t know about the alarming signs of stroke. The most frequent response (26.16%) to immediate management of stroke was to take the individual to Emergency Department/hospital. In all 56% reported that basic information about stroke was given to them by friend/relative.CONCLUSIONS: The overall awareness of the study population regarding stroke was shown to be inadequate by this study. Knowledge was significantly greater in participants of younger age and a higher level of education