Medicine and Health Sciences Commons^™

Utility And Accuracy Of Primary And Secondary Ultrasonographic Signs For Diagnosing Acute Appendicitis In Pediatric Patients, W. Akhtar, Mujtaba Z. Naveed, Kumail Khandwala

Department of Radiology

Introduction Making an accurate diagnosis of acute appendicitis (AA) is vital to prevent the morbid complications associated with untreated AA. This is challenging in up to 30% of pediatric patients which is a significantly high number. Ultrasound (US) has been generally used as the initial mode of imaging in pediatric patients due to the lack of ionizing radiation. Given its variable accuracy, adjuvants such as secondary signs can be used to aid the radiologist in making an accurate diagnosis. Materials and methods Patients between the ages of two and sixteen years with acute abdominal pain suspicious for AA, who underwent …

Radiological And Clinical Outcomes In Patients Undergoing Anterior Cervical Discectomy And Fusion: Comparing Titanium And Peek (Polyetheretherketone) Cages, Muhammad Junaid, Mamoon Ur Rashid, Syed Sarmad Bukhari, Mamoon Ahmed

Section of Neurosurgery

Objectives: To study clinical and radiological outcomes in patients who had undergone the procedure of anterior cervical discectomy and fusion with titanium or PEEK (polyetheretherketone) cages for cervical disc prolapse.
Methods: This is a retrospective/non-randomized study which was conducted at the Combined Military Hospital Peshawar. Study interval was four years from 1st October, 2010 to 31st September, 2014. Total number of included patients were 149. All of the patients had undergone the procedure of anterior cervical discectomy and fusion with titanium or PEEK (polyetheretherketone) cages. All of the patients had plain MRI cervical spine done for diagnosis of anterior cervical …

Prevalence Of Subarachnoid Haemorrhage Among Patients With Cranial Venous Sinus Thrombosis In The Presence And Absence Of Venous Infarcts, Muhammad Azeemuddin, Muhammad Awais, Fatima Mubarak, Noor Ul-Ain Baloch

Department of Radiology

Introduction: In patients with cranial venous sinus thrombosis, the occurrence of subarachnoid haemorrhage in association with haemorrhagic venous infarcts is a well described phenomenon. However, the presence of subarachnoid haemorrhage in patients with cranial venous sinus thrombosis in the absence of a haemorrhagic venous infarct is exceedingly rare.
Methods: We retrospectively reviewed charts and scans of all patients who had cranial venous sinus thrombosis confirmed by magnetic resonance venography at our hospital between September 2004 and May 2015. The presence of subarachnoid haemorrhage was ascertained on fluid-attenuated inversion recovery, susceptibility-weighted imaging and/or unenhanced computed tomography scans by a single experienced …

Role Of Adc Values And Ratios Of Mri Scan In Differentiating Typical From Atypical/Anaplastic Meningiomas, Muhammad Azeemuddin, Waseem Mehmood Nizamani, Muhammad Usman Tariq, Mohammad Wasay

Department of Radiology

Atypical/anaplastic meningiomas are prone to aggressive behaviour which affects treatment planning and prognostication. Our aim was to assess the role of Apparent Diffusion Coefficient (ADC) values of MRI brain in differentiating typical from atypical/anaplastic meningioma. We reviewed 84 typical and 37 atypical/anaplastic meningiomas and compared mean ADC values and ADC ratios of their preoperative MRI brain. At 3 Tesla, mean ADC value for typical meningioma was1.03±0.10x10-3 and 0.63±0.05x10-3 for atypical/anaplastic meningioma. At 1.5 Tesla, mean ADC value for typical meningioma was 1.05±0.11x10-3 and atypical/ anaplastic meningioma was 0.70 ± 0.04x10-3. The mean ADC ratios were 1.08 ± 0.17 and 0.85 …

Clinical Audit To Assess Delays In Chemotherapy Administration At Daycare Oncology Center At A Tertiary Care Hospital In Karachi, Pakistan, Arifa Arifa Aziz, Zarka Samoon, Afsheen Feroz, Nadia Ayoub, Safia Awan, Madhia Beg

Department of Radiation Oncology

Aim: There were delays reported by patients in chemotherapy administration in daycare oncology. Therefore, we decided to audit all processes which are involved in chemotherapy administration. The objective was to improve our service by decreasing the time between admission and initiation of chemotherapy and identify the reasons for delays. Materials and Methods: The audit was conducted in three parts. In Review I, audit tool was developed and information documented of 109 patients receiving chemotherapy at daycare center from April 14 to May 13, 2015. Five processes were assessed out of which delay in initial assessment by the nurse was the …

Role Of Multi-Parametric (Mp) Mri In Prostate Cancer, Syed Muhammad Nazim, Ather Enam, Basit Salam

Section of Urology

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 …

Twin Reversed Arterial Perfusion Sequence: Assessing The Role Of The Correct Imaging Modality In A Rare Clinical Entity, Imrana Masroor, Sarah Saleem, Aliya Aziz, Romana Idress

Department of Radiology

Acardiac twin formation is a rare anomaly. It is one of the most extreme complications of monozygotic twin pregnancies. Such occurrences are brought about when a normal twin donates blood to an abnormal twin through its umbilical arteries via vascular anastomoses at the level of the placenta, which is termed as twin reversed arterial perfusion sequence (TRAPS). Twin reversed arterial perfusion sequence is considered a rare variant of twin-to-twin transfusion syndrome. Due to the considerable blood transfer from the healthy twin to the parasitic one, cardiac failure can ensue in the healthy twin. The mortality of the acardiac twin is …

Higher Event Rate In Patients With High-Risk Duke Treadmill Score Despite Normal Exercise-Gated Myocardial Perfusion Imaging, Maseeh Uz Zaman, Nosheen Fatima, Areeba Zaman, Unaiza Zaman, Rabia Tehseen, Sidra Zaman

Department of Radiology

his prospective study was carried out to find the negative predictive value of various Duke Treadmill Scores (DTSs) in patients with normal myocardial perfusion imaging (MPI). This study was conducted from August 2012 to July 2015, and 603 patients having normal exercise MPIs were included. Patients were followed for 2 years for fatal myocardial infarction (FMI) and nonfatal myocardial infarction (NFMI). Follow-up was not available in 23 patients, leaving a cohort of 583 participants. DTS was low risk (≥5) in 286, intermediate risk (between 4 and - 10) in 211, and high risk (≤-11) in 86 patients. Patients with high- …

Unicameral Bone Cysts: Current Concepts, Shahryar Noordin, Salim Allana, Masood Umer, Mujahid Jamil, Kiran Hilal, Nasir Ud Din

Section of Orthopaedic Surgery

Unicameral bone cysts (UBC) or simple/solitary bone cysts are benign fluid filled cavities that enlarge over time, resulting in thinning of the bone. Usually these cysts are reported in the metaphyseal areas of long bones with open physes. 85% of UBCs occur almost exclusively in children and adolescents. UBCs are more aggressive in the first decade of life and correspondingly the recurrence rate for these patients is four times that for adolescents. The proximal humerus and femur account for almost 90% of these cases. UBCs are classified as active when they are within 1 cm of the physis and latent …

Metachronous Renal Ewing Sarcoma/Primitive Neuroectodermal Tumour In A Survivor Of Burkitt Lymphoma, Kumail Khandwala, Kiran Hilal, Zehra Fadoo, Khurram Minhas

Department of Radiology

We present a case of a 14-year-old girl who was diagnosed with Burkitt lymphoma in 2014. She was managed with chemotherapy and remained in remission for 3 years. On her surveillance imaging in 2017, a left-sided renal neoplastic mass was incidentally discovered. She underwent nephrectomy and pathology of the resected specimen revealed small cell tumour of the kidney with features favouring renal Ewing sarcoma/primitive neuroectodermal tumour. Molecular genetic analysis by fluorescence in situ hybridisation was performed which showed translocation of 22q12, thereby confirming the diagnosis. This is a rare secondary malignancy and an unusual association. This case highlights the importance …

Collaborative Task-Sharing To Enhance The Point-Of-Care Ultrasound (Pocus) Access Among Expectant Women In Kenya: The Role Of Midwife Sonographers, Sudhir Vinayak, Sharon Brownie

Imaging & Diagnostic Radiology, East Africa

Unrealized maternal and child health goals continue to challenge Kenya where adverse outcomes remain high and diagnostic services are limited. The acute shortage of doctors and radiographers requires alternate human resources for health (HRH) with the ability to identify risk factors in pregnancy through Point-Of-Care Ultrasound (POCUS). A specialist radiologist and ultrasonography team partnered with midwives to adopt interprofessional task sharing and capacity building. Faculty from the Radiology Department of our hospital designed and implemented the project which was carried out at three outreach health service centres. Designing and implementing a training model to skill midwife sonographers with the capacity …

Lumbar Artery Pseudoaneurysm Following Renal Biopsy., Basit Salam, Kumail Khandwala

Department of Radiology

Lumbar artery pseudoaneurysms have previously been described as rare iatrogenic complications following percutaneous interventional procedures involving the flanks. We describe a case of a 71-year-old man who became unstable and dropped 3 grams of hemoglobin within 24 hours following renal biopsy. A post-biopsy hemorrhage was suspected, and a pseudoaneurysm of his second right lumbar (L2) artery was found on computed tomography angiogram (CTA). Successful coil embolization was performed in the right L2 artery. This case discusses the diagnostic and therapeutic challenges of this unusual complication as well as the anatomical and technical factors involved in the embolization of the lumbar …

Routine Antenatal Ultrasound In Low- And Middle-Income Countries: First Look - A Cluster Randomised Trial, Robert L. Goldenberg, Robert O. Nathan, David Swanson, Sarah Saleem, Waseem Mirza, Fabian Esamai, David Muyodi, Ana L. Garces, Lester Figueroa, Elwyn Chomba

Community Health Sciences

Objective: Ultrasound is widely regarded as an important adjunct to antenatal care (ANC) to guide practice and reduce perinatal mortality. We assessed the impact of ANC ultrasound use at health centers in resource-limited countries.
Design: Cluster randomized trial.
Settings: Clusters within five countries (Democratic Republic of Congo, Guatemala, Kenya, Pakistan and Zambia).
Methods: Clusters were randomized to standard ANC or standard care plus two ultrasounds and referral for complications. The study trained providers in intervention clusters to perform basic obstetric ultrasounds.
Main Outcome Measures: The primary outcome was a composite of maternal mortality, maternal near-miss mortality, stillbirth, and neonatal mortality. …

Experiences Of The Breast Cancer Patients Undergoing Radiotherapy At A Public Hospital Peshawar Pakistan, Gulzar Habibullah, Raisa Raisa, Shanaz Hussein Cassum, Rehana Elahi

School of Nursing & Midwifery

Objective: This study aimed to explore the experiences of female breast cancer patients undergoing radiotherapy (RT) in a public hospital in Peshawar, Pakistan.
Methods: This study employed a descriptive exploratory method. A purposive sample of 14 breast cancer women undergoing RT was selected for this study. Data were collected over the period of 5 months, using a semi-structured interview guide and conducting in-depth face-to-face interviews. These interviews were audio taped and transcribed by a bilingual transcriber. The translated version of the interview was coded, and the analysis was done manually.
Results: Four main categories emerged from data analysis, which were: …

Diagnostic Accuracy Of Pelvic Mri For Determination Of The Cervical Involvement In Endometrial Cancer., Imrana Masroor, Sadia Rashid, Shaista Afzal Saeed, Saira Naz, Muhammad Azeemuddin

Department of Radiology

OBJECTIVE: To determine the diagnostic accuracy of pelvic MRI for assessment of the cervical involvement in endometrial cancer.

STUDY DESIGN: Cross-sectional analytical study.

PLACE AND DURATION OF STUDY: Radiology Department of the Aga Khan University Hospital, Karachi from January 2014 to December 2015.

METHODOLOGY: Patients with biopsy-proven endometrial cancer were included, who had both their MRI and histopathological diagnosis performed at our institution. Those patients treated with chemo/radiotherapy or had incomplete medical records, were excluded. The extent of cervical involvement by endometrial carcinoma was seen on T2WI images, and findings were correlated after surgery taking histopathology as the gold standard. …

Accuracy Of Specimen Radiography In Assessing Complete Local Excision With Breast-Conservation Surgery, Saira Naz, Imrana Masroor, Shaista Afzal Saeed, W. Akhtar, Sehrish Butt, Zafar Sajjad, Anwar Ahmad

Department of Radiology

OBJECTIVE: The aim of this study was to evaluate the accuracy of “X- ray examination of surgically resected specimen‘‘ in assessing complete local excision (CLE).

MATERIALS AND METHODS: In this retrospective cross sectional study, data were collected for all female breast cancer cases who underwent breast-conserving surgery after needle localization of mammographically visible disease. Males, patients with mammographically invisible disease and cases with benign or inconclusive histopathology, those undergoing modified radical mastectomy and individuals with dense breast parenchyma were excluded. We evaluated radiography of resected specimens to assess margin spiculation, distance of mass/microcalcification from the excised margin, presence of a …

Myocardial Perfusion Imaging: The Gatekeeper And Advisor, Maseeh Uz Zaman, Nosheen Fatima

Department of Radiology

No abstract provided.

Massive Tumor Thrombus In Left Renal Vein Andiinferior Vena Cava In Renal Cell Carcinoma On 18-Fluorodeoxyglucose Positron Emission Tomography/Computerized Tomography: "Suspension Bridge Sign"., Maseeh Uz Zaman, Nosheen Fatima, Unaiza Zaman, Rabia Tahseen, Sidra Zaman

Department of Radiology

Tumor thrombosis is a relatively uncommon complication of renal cell carcinoma (RCC), and its diagnosis has therapeutic and prognostic implication. Computerized tomography (CT) is the primary imaging modality for staging RCC, but it has low sensitivity to differentiate between tumor thrombus and bland or benign thrombus. 18-fluorodeoxyglucose positron emission tomography/CT (PET/CT) has a limited role in diagnosis and staging of RCC, but its diagnostic accuracy is considerably high for detection of metabolically active tumor thrombus. We are presenting a case of metastatic left-sided RCC with massive hypermetabolic tumor thrombus extending from left kidney to left renal vein and inferior vena …

Resolution Of Symptomatic Secondary Empty Sella Syndrome Following Lumbar-Peritoneal Shunt., Waseem Mehmood Nizamani, Mubbashira Siddiqui, Sehrish Nizar Ali Momin, Waqas Muhammad, Rashid Jooma

Department of Radiology

Background: Post‑surgical empty sella is related to the removal of pituitary tumors either from the transcranial or transphenoidal route, rendering diaphragma sellae incompetent at the end of the procedure. This subsequently leads to herniation of the third ventricle and optic apparatus into the empty sella. Studies have shown that in 50% of the cases, individuals with primary and secondary empty sella syndrome have developed defects in the visual fields. Benign increased intracranial pressure, cerebrospinal rhinorrhea, papilledema, and abnormalities affecting visual acuity may also occur as a result of empty sella.

Case Description: This case report discusses a rare treatment …

A Variant Of Crossed Pulmonary Arteries In Association With Coarctation Of Aorta, Rabail Raza, Kumail Khandwala, Hafsa Qayyum, Muhammad Anwar Saeed, Anwar Ahmad

Department of Radiology

Crossed or "crisscross" pulmonary arteries (CPA) are a result of an anomalous origin and course of both the pulmonary arteries from the main pulmonary trunk in which the left pulmonary artery (PA) ostium usually lies directly superior and to the right PA ostium after which they cross each other and supply their respective lungs. This condition is usually associated with conotruncal malformations and genetic syndromes. We describe a case report of an infant, suspected to have Down syndrome, who was diagnosed with CPA and coarctation of aorta on computed tomography (CT) angiography. Our case is unusual because in our patient …

Clinicoradiological Correlation Of Infarct Patterns On Diffusion-Weighted Magnetic Resonance Imaging In Stroke, Zainab Hussain, Kiran Hilal, Muhammad Ahmad, Zafar Sajjad, Raza Sayani

Department of Radiology

Diffusion-weighted magnetic resonance imaging (DW-MRI) represents a major advance in the early diagnosis of acute ischemic stroke. It can detect edema due to ischemia in the brain tissue. It not only establishes the presence and location of ischemic brain injury but also a relatively new concept is the determination of infarct patterns seen on diffusion imaging and its clinical correlation. Objective To determine the frequency of various infarct patterns and their relationship with functional outcome of the patient. Materials and methods A total of 108 patients with acute stroke were enrolled by purposive sampling. Magnetic resonance imaging (MRI) was obtained …

Diagnostic Efficiency Of Multidetector Computed Tomography In The Evaluation Of Clinically Equivocal Cases Of Acute Appendicitis With Surgical Correlation, Jawaid Iqbal, Raza Sayani, Misbah Tahir, Syed Mustahsan

Department of Radiology

Acute appendicitis is one of the most frequent causes of lower abdominal pain and requires immediate surgical intervention. The diagnosis often poses a lot of challenge even to experienced surgeon. Those patients with equivocal symptoms may require different imaging modalities like radiography, contrast examination and ultrasound with limited utility. Multidetector computed tomography (MDCT) used in suspected acute appendicitis has, however, resulted in improved diagnostic accuracy and also reduction of negative surgeries. Objective We intend to determine the diagnostic efficiency of MDCT in clinically equivocal cases of acute appendicitis correlating it with surgical/histopathological findings. Materials and methods A group of 116 …

Melas: A Complex And Challenging Diagnosis, Kumail Khandwala, Anwar Ahmad, Taha Sheikh

Department of Radiology

Mitochondrial encephalopathy, lactic acidosis and stroke-like episodes (MELAS) is a rare multisystem disorder and is the most common maternally inherited mitochondrial disease. This condition has a special predilection for the nervous system and muscles. Typical findings on brain imaging include stroke-like areas, calcification of basal ganglia and brain atrophy. This accounts for the disease being, both clinically and radiologically, mistaken for ischemic stroke. The differentiation features from stroke include comparatively young age of the patients, site of the lesions, and relative overlap between the cerebral vasculature territories. In this case report, we discuss a 16-year male with clinical and radiological …

Melas: A Complex And Challenging Diagnosis, Kumail Khandwala, Anwar Ahmad, Taha Sheikh

Department of Radiology

Mitochondrial encephalopathy, lactic acidosis and stroke-like episodes (MELAS) is a rare multisystem disorder and is the most common maternally inherited mitochondrial disease. This condition has a special predilection for the nervous system and muscles. Typical findings on brain imaging include stroke-like areas, calcification of basal ganglia and brain atrophy. This accounts for the disease being, both clinically and radiologically, mistaken for ischemic stroke. The differentiation features from stroke include comparatively young age of the patients, site of the lesions, and relative overlap between the cerebral vasculature territories. In this case report, we discuss a 16-year male with clinical and radiological …

Role Of 18 Fdg Pet/Ct In Breast Cancer., Nosheen Fatima, Maseeh Uz Zaman

Department of Radiology

No abstract provided.

Fibrolipomatous Hamartoma Of The Median Nerve With Macrodystrophia Lipomatosa, Muhammad Azeemuddin, Adeel A. Waheed, Noman Khan, Raza Sayani, Anwar Ahmad

Department of Radiology

Fibrolipomatous hamartoma (FLH) is a rare congenital condition that presents with a benign overgrowth of the bone and fibroadipose tissue termed as macrodystrophia lipomatosa (MDL). Although commonly seen in the median nerve, other peripheral nerves can be involved. Diagnosis can be made on magnetic resonance imaging (MRI) due to the characteristic coaxial cable appearance on axial images and the spaghetti appearance on sagittal images. Histology shows mature adipose and fibrous tissue infiltrating the epineural and perineural compartments. Multiple or debulking surgeries are often needed, with an emphasis on cosmetic aspects. We present one such case in which wide margin excision …

Role Of Interventional Radiology In The Management Of Peripheral Vascular Malformations: A Tertiary Care Center Experience., Misbah Tahir, Muhammad Anees Mumtaz, Anum Sultan, Raza Sayani

Department of Radiology

Peripheral vascular malformations (PVMs) represent a wide spectrum of vascular abnormalities occurring due to anomalous connections between arteries, veins, capillaries, and lymphatic channels at the microscopic level, in different combinations. They are rare and challenging to treat. Different operators may have different approaches based on their experience and expertise. Sclerotherapy either alone or in combination with embolization has been used as an independent method for the treatment of PVMs. Purpose The aim of this study is to assess the safety and efficacy of sclerotherapy and embolization, with or without surgery, for the treatment of peripheral vascular malformations, based on our …

Multiple System Atrophy - The Cerebellar Type With “Hot Cross Bun Sign” On Mri, Rehana Shaikh, Saba Sohail, Nasreen Naz

Department of Radiology

Multiple system atrophy (MSA) is an adult onset, progressive, idiopathic neurodegenerative disease that clinically manifest as MSA-C with cerebellar signs predominant, MSA-P with Parkinsonian features predominant and MSA-A with autonomic signs and symptoms. MRI has an important role in its diagnosis with a characteristic finding described as "hot cross bun" sign seen in MSA of cerebellar type (MSA-C). We have seen two cases of MSA-C referred to Radiology Department, Civil Hospital Karachi in February 2017 and March 2017 who presented with difficulty in walking and speech and foecal and urinary incontinence. The MRI showed atrophy of pons, cerebellum and middle …

Mra-Based Evaluation Of Anatomical Variation Of Circle Of Willis In Adult Pakistanis, Rehana Shaikh, Saba Sohail

Department of Radiology

Objective: To determine the frequency and patterns of normal anatomical variation of Circle of Willis on magnetic resonance angiogram in adults without cerebrovascular disease.
Methods: This descriptive cross-sectional study was conducted at the Radiology Department of Dow University of Health Sciences / Civil Hospital, Karachi, from January to December 2016, and comprised patients referred for magnetic resonance imaging of the brain and magnetic resonance angiogram without any clinical or radiological manifestation of cerebrovascular disease, primarily including those with suspected demyelination, infection, epilepsy or metastases. Three-dimensional time-of-flight magnetic resonance angiography was performed. The Circle of Willis was assessed for its completeness …

Cesarean Scar Pregnancy: An Experience Of Three Cases With Review Of Literature, Gulnaz Shafat, Kumail Khandwala, Hina Iqbal, Shaista Afzal Saeed

Department of Radiology

Cesarean scar pregnancy (CSP), often considered the rarest form of ectopic pregnancy, is a result of implantation of the gestational sac into the fibrous tissue scar of a previous cesarean section. With an increase in the rate of cesarean sections, along with better awareness and improvement in sonographic diagnosis, the number and detection of scar pregnancies are on the rise. Because of its early invasion of the myometrium, usually in the first trimester, CSP is considered to be potentially lethal, leading to high risks of uterine rupture. We report a series of three cases of scar pregnancy that presented at …