Wunderlich Syndrome Managed with Angiomyolipoma Embolization - Renal Artery Anatomic Variant Augmenting Safe and Nephron-Sparing Intervention.

Background: Wunderlich syndrome is an uncommon entity characterized by spontaneous, nontraumatic renal bleeding into the subcapsular and perirenal regions. The most frequent benign tumor, angiomyolipoma, is the most common cause of Wunderlich syndrome. Case presentation: We report a case of Wunderlich syndrome in angiomyolipoma. Intratumoral pseudoaneurysm arising from feeders of an accessory renal artery supplying the lower pole of the kidney was selectively embolized. Rarely does a sporadic renal angiomyolipoma develop a giant pseudoaneurysm. Conclusion: Transarterial embolization is imperative to control the bleeding or as a preventative measure to reduce the risk of intralesional pseudoaneurysm rupture. When vascular interventional facilities are unavailable, surgery may be necessary.

The injury pattern and outcomes among elephant attack survivors presenting to the emergency department: A retrospective observational study.

BACKGROUND: Human-elephant conflicts (HECs) are becoming a disturbing public health concern in eastern India. This study highlights the pattern of injuries, epidemiological factors, and outcomes among the victims who survived an elephant attack (EA). METHODS: This retrospective observational study was conducted in a tertiary care hospital. Data were retrieved from the medical records of EA victims who presented to the emergency department of the hospital over five years (January 2019-January 2024). Data regarding sociodemographic characteristics, injury mode, injury pattern, radiological findings, emergency procedures, and outcome variables (admission, length of intensive care unit and hospital stay, and death) were collected. RESULTS: In total, 45 EA victims were included in this study. The mean participant age was 45.8 ± 14.57 years. Of the total participants, 35 (78 %) were men. Most EAs [n = 18 (40 %)] occurred in the forest area and during the early morning hours between 4am and 8am [n = 18 (40 %)] of the winter season [n = 37 (82 %)] and were unprovoked [38 (84 %)]. Of the total injuries, 26 (67 %) injuries were due to the direct mode of EA and 13 (33 %) were due to the indirect mode. The most common mechanism of EA was using the trunk and foot [20 (51 %)], followed by the tusk [6 (15 %)]. The median ISS in victims was 20 (13-29). The median AIS score of chest injuries was 1 (0-3). Thirteen (29 %) patients were positive on e-FAST. Of the total EA victims, 12 (26 %) were admitted to the intensive care unit (ICU) and 17 were admitted to the wards. Severe chest injury (AIS score ≥ 3) (p = 0.003), direct mode of injury, and polytrauma (ISS > 16) were identified as significant factors contributing to ICU admission. The median ICU stay of the victims was 6 (3-8) days, and the median length of hospital stay was 7 (0.5-11) days. One inpatient mortality was noted. CONCLUSION: Middle-aged men were the most common victims of EA occurring during the early morning hours. Extremity and soft tissue injuries were most common, followed by chest and abdominal injuries. Severe chest injury resulted in ICU admission and extended hospitalization.

Incidental 68Ga-PSMA Uptake in the Benign Enchondroma-A Rare Finding on 68Ga-PSMA PET/CT.

ABSTRACT: 68Ga-PSMA (prostate-specific membrane antigen)-HBED-CC (N,N'-bis[2-hydroxy-5-(carboxyethyl)benzyl]ethylenediamine-N,N'-diacetic acid) PET/CT is the new advancement in oncological imaging. However, false-positive uptake can be seen in benign lesions on 68Ga-PSMA PET/CT. We describe a rare case of intense 68Ga-PSMA uptake in an enchondroma confirmed on MRI.

Hydrogen-induced tunable remanent polarization in a perovskite nickelate.

Materials with field-tunable polarization are of broad interest to condensed matter sciences and solid-state device technologies. Here, using hydrogen (H) donor doping, we modify the room temperature metallic phase of a perovskite nickelate NdNiO3 into an insulating phase with both metastable dipolar polarization and space-charge polarization. We then demonstrate transient negative differential capacitance in thin film capacitors. The space-charge polarization caused by long-range movement and trapping of protons dominates when the electric field exceeds the threshold value. First-principles calculations suggest the polarization originates from the polar structure created by H doping. We find that polarization decays within ~1 second which is an interesting temporal regime for neuromorphic computing hardware design, and we implement the transient characteristics in a neural network to demonstrate unsupervised learning. These discoveries open new avenues for designing ferroelectric materials and electrets using light-ion doping.

Case of Ectopic Variceal Bleed Managed With Percutaneous Transhepatic Portal Vein Recanalization.

A variety of complications and associated clinical presentations may be seen in patients with cirrhotic and non-cirrhotic portal hypertension. We present one such case of Upper GI hemorrhage from ectopic duodenal varices in a case of pre-hepatic portal hypertension due to Extrahepatic Portal Venous Obstruction (EHPVO). The case was managed successfully with endovascular Portal Vein Recanalization (PVR) and metallic stent deployment. With adequate technical success, improved symptoms, and laboratory parameters, the patient was discharged on long-term anticoagulation and interval follow-up.

Acute ischaemic stroke and deep vein thrombosis following snakebite.

Snakebite envenomation remains a neglected tropical public health issue claiming thousands of lives every year. It is a common medical emergency and a threat to the impoverished populations of low-income and middle-income countries including India. A combination of ischaemic stroke and deep vein thrombosis is a devastating duo complication of snake bite, with no literature report to date. Here, the authors report an unusual case of a young woman developing ischaemic stroke and deep vein thrombosis following snakebite even after the use of antivenom. MRI brain showed right thalamic infarct with haemorrhagic transformation and, ultrasound Doppler revealed right lower limb deep vein thrombosis. The pathophysiology of deep vein thrombosis and ischaemic stroke is complex. It is believed that the activation of the coagulation cascade, complement system together with endothelial injury and immune activation leads to inflammation, thrombosis and occlusion of smaller and even larger vessels.

Emergency endovascular and percutaneous urological interventions: A pictorial review.

Emergency endovascular and percutaneous urological interventions encompass various diagnostic and therapeutic procedures to address various genitourinary conditions. These urological interventions are life-saving in addressing complications following biopsy, post-nephrectomy, post-transplant, and post-trauma. Compared to other surgical fields, there are relatively fewer urological emergencies. However, they require prompt radiological diagnosis and urgent interventions. This pictorial essay emphasizes various urological emergencies and urgent interventional management.

Radioiodine Uptake at Suture Site Granuloma Mimicking Neck Node Metastasis on 131 I Whole-Body Iodine Scintigraphy.

ABSTRACT: Differentiated thyroid carcinoma constitutes over 90% of all thyroid cancers. The standard treatment approach involves total or near-total thyroidectomy with or without neck dissection followed by 131 I whole-body scintigraphy (WBS) to detect local or distant metastases. Radioiodine offers high sensitivity and specificity for detection of metastatic disease in well differentiated thyroid carcinoma. However, despite its high accuracy, 131 I WBS demonstrates false-positive results, mostly at inflammatory or infective site. These false-positive radioiodine accumulation can lead to misdiagnosis and unwarranted radioiodine treatment. This case presents localization of 131 I to the suture site granuloma leading to false-positive results on 131 I WBS.

Bloody Bile and Rescue Intervention-A Case Series of Post-PTBD Hemorrhagic Complications With a Review of the Literature.

Percutaneous transhepatic biliary drainage (PTBD) is a routinely performed interventional radiological procedure. A myriad of complications can occur after PTBD, the most important being hemorrhagic complications that require immediate attention. Hemorrhage following PTBD may result from arterial, portal, or hepatic venous injury. A catheter or pull-back cholangiogram often demonstrates the venous injury. A computed tomogram angiogram aids in identifying bleeding sources and procedural planning. Catheter repositioning, upsizing, or clamping often suffice for minor venous bleeding. However, major venous injury necessitates tract embolization, portal vein embolization, or stent grafting. Arterial injury may lead to significant blood loss unless treated expeditiously. Transarterial embolization is the treatment of choice in such cases. Adequate knowledge about the hemorrhagic complications of PTBD will allow an interventional radiologist to take necessary precautionary measures to reduce their incidence and take appropriate steps in their management. This article entails four different hemorrhagic complications of PTBD and their interventional management. It also discusses the various treatment options to manage different kinds of post-PTBD hemorrhagic complications.

Is salvage Plug-Assisted Retrograde Transvenous Obliteration (PARTO) safe and effective for bleeding gastric varices ?- A preliminary single-center experience.

BACKGROUND: Vascular plug-assisted retrograde transvenous obliteration (PARTO) obliterates the gastric varices and portosystemic shunt, thus resulting in a lower rebleeding rate than endoscopic glue/sclerotherapy. AIMS: To evaluate the safety and efficacy of PARTO as salvage therapy in liver cirrhosis with gastric variceal bleed (GVB) after failed endotherapy. We assessed the clinical success rate and changes in liver function at 6- months. MATERIALS AND METHODS: Patients who underwent salvage PARTO after failed endotherapy for GVB (between December 2021 and November 2022) were searched and analyzed from the hospital database. Clinical success rate and rebleed rate were obtained at six months. Child-Pugh score (CTP) and Model for end-stage liver disease (MELD) score were calculated and compared between baseline and 6-month follow-up. RESULTS: Fourteen patients (n = 14, Child-Pugh class A/B) underwent salvage PARTO. Nine had GOV-2, and five had IGV-1 varices. The mean shunt diameter was 11.6 ± 1.6 mm. The clinical success rate of PARTO was 100% (no recurrent gastric variceal hemorrhage within six months). No significant deterioration in CTP (6.79 ± 0.98 vs. 6.21 ± 1.52; p = 0.12) and MELD scores (11.5 ± 4.05 vs. 10.21 ± 3.19; p = 0.36) was noted at 6 months. All patients were alive at 6 months. One patient (n = 1, 7.1%) bled from esophageal varices after three days of PARTO and was managed with variceal banding. 21.4% (3/14) patients had progression of esophageal varices at 6 months requiring prophylactic band ligation. Three patients (21.4%) had new onset or worsening ascites and responded to low-dose diuretics therapy. CONCLUSIONS: PARTO is a safe and effective procedure for bleeding gastric varices without any deterioration in liver function even after six months. Patient selection is critical to prevent complications. Further prospective studies with larger sample size are required to validate our findings.

Role of contrast-enhanced ultrasound for differentiation of benign vs. malignant portal vein thrombosis in hepatocellular carcinoma - A systematic review a meta-analysis.

Introduction/Purpose: Patients with cirrhosis and hepatocellular carcinoma (HCC) can develop both benign and malignant portal vein thrombosis (PVT). Characterising the nature of PVT is important for planning an optimal therapeutic strategy. In the absence of typical findings or contraindications to computed tomography (CT) or magnetic resonance imaging (MRI), contrast-enhanced ultrasound (CEUS) could help in this differentiation. The present meta-analysis aimed to evaluate the performance of CEUS for characterising PVT in patients with HCC. Methods: Electronic databases of PubMed, Embase and Scopus were searched from inception to 31 December 2022 for studies analysing the role of CEUS in the differentiation of benign and malignant PVT in HCC. Using the bivariate random effect model, pooled sensitivity and specificity were calculated, and the summary receiver operating characteristic (sROC) curve was plotted. Results: A total of 12 studies with data from 712 patients were included in the meta-analysis. The pooled sensitivity and specificity of CEUS for the diagnosis of tumour in vein were 97.0% (95% CI: 93.0-98.7) and 96.8% (95% CI: 92.1-98.7), respectively, without significant heterogeneity. A sROC curve was plotted, and the area under the receiver operating characteristic was 0.99 (95% CI: 0.98-1.00). Despite the presence of publication bias, sensitivity analysis did not show any change in sensitivity and specificity. Discussion: Our meta-analysis summarises the accuracy data from 12 studies, including >700 subjects. Contrast-enhanced ultrasound had excellent diagnostic accuracy with pooled sensitivity and specificity of 97.5% (95% CI: 93.5-99.1) and 98.2% (95% CI: 91.5-99.6), respectively, without any significant heterogeneity. Additionally, the pooled positive LR, negative LR and DOR were 54.6 (95% CI: 11.1-25.6), 0.02 (0.01-0.07) and 2186.8 (318.3-15022.2), respectively. A positive result increases the pretest probability of malignant PVT from 50% to 98%, whereas a negative result decreases it from 50% to 2%. Most of the studies included in our meta-analysis used identical techniques and 6-12-month follow-up scans to check for thrombus progression or regression. Our analysis showed no significant heterogeneity in the studies, and area under receiver operating characteristic curve (AUROC) with 95% CI was 1.00 (95% CI: 0.99-1.00). This critical meta-analysis thus propels CEUS to the forefront for differentiating benign from tumoural PVT and suggests routinely using CEUS in patients presenting with HCC and evidence of thrombus on greyscale ultrasound. Conclusion: Contrast-enhanced ultrasound is an effective diagnostic modality differentiation of benign and malignant PVT in patients with HCC and can be an alternative modality to CT or MRI. Further studies are required to study the role of CEUS as initial diagnostic modality for the characterisation of PVT in HCC.

A lung cyst harbouring a congenital pulmonary varix.

A non-smoker man in his second decade presented to a medical centre with intermittent haemoptysis over 2 years. The haemoptysis was infrequent initially to be ignored, but later, the episodes increased in amount and frequency. Routine blood tests including coagulation profile showed normal results. The chest radiography and echocardiography were normal. The contrast-enhanced CT scan of the chest showed a cystic lesion with intracystic abnormality and surrounding ground-glass opacity in the left upper lobe. The CT pulmonary angiography and invasive pulmonary angiography showed the abnormality to be a dilated pulmonary vessel draining into the left atrium, thereby confirming the diagnosis of congenital pulmonary varix contained within a lung cyst. The patient underwent a successful lobectomy following which he experienced no further haemoptysis.

Liver volumetry in cirrhotic patients with or without hepatocellular carcinoma: Its correlation with Child-Pugh, model for end-stage liver diseases and indocyanine green dye test.

BACKGROUND AND OBJECTIVES: To evaluate the correlation between non-tumoral liver volume (NTLV) by computed tomography (CT) volumetry and indocyanine green retention at 15 minutes (ICG-r15%), Child-Pugh score (CTP) and model for end-stage liver diseases (MELD) score in cirrhotic patients having hepatocellular carcinoma (HCC) (group A) and in cirrhotics without HCC (group B). METHODS: As many as 111 consecutive patients with liver cirrhosis, who underwent triple-phase CT abdomen, were retrospectively included in our study. They were classified into group A (cirrhosis with HCC, n = 69) and group B (cirrhosis only, n = 42). Segmental liver volume, tumor and NTLV were calculated using Myrian XP-Liver segmentation software. In group B, NTLV was the same as the total liver volume (TLV). The correlation of NTLV with ICG-r15%, CTP and MELD scores was analyzed using appropriate correlation tests for each group. RESULTS: NTLV had a good and significant negative correlation with ICG-r15% (ρ = - 512; p < 0.001) in group A, but not in group B. It also had a significant negative correlation with CTP (ρ = - 251; p = 0.038) and MELD (ρ = - 323; p = 0.007) scores only in group A. Furthermore, ICG-r15% had a good and significant positive correlation with CTP and MELD scores in both groups (p < 0.05). CONCLUSION: NTLV showed a significant negative correlation with ICG-r15% in cirrhotic patients with HCC, but not in cirrhotic patients without HCC. Therefore, CT volumetry can be a valuable tool to predict the functional hepatic volume in patients of cirrhosis with HCC subjected for hepatectomy, where a facility of ICG-r15% is not available. However, further studies are needed to validate our findings in cirrhotic only patients.

Impact of nutritional status on the outcome of transjugular intrahepatic portosystemic shunt in patients with cirrhosis: a systematic review.

OBJECTIVES: Malnutrition and sarcopenia have been reported to adversely affect the outcome of patients with cirrhosis of the liver. There is an emerging body of evidence suggesting malnutrition and sarcopenia increase the risk of hepatic encephalopathy (HE) and mortality after transjugular intrahepatic portosystemic shunt (TIPS). The current systematic review aims to determine whether the body of evidence supports an association between nutritional status and post-TIPS outcomes in patients with cirrhosis. METHODS: Electronic databases of PubMed, Embase, and Scopus were searched from inception to June 3, 2023, for studies analysing the effect of nutritional status on post-TIPS outcomes in patients with cirrhosis. RESULTS: A total of 22 studies were included in the systemic review. Assessment of sarcopenia was done by skeletal muscle index (SMI) at the L3 level, transversal psoas muscle thickness, psoas muscle density, malnutrition as per ICD, relative sarcopenia with excess adiposity, lipid profile, controlling nutritional status score, body composition analysis, hospital frailty risk score, and visceral and subcutaneous fat area index. Ten out of 12 studies in this systematic review showed a significant association with the incidence of post-TIPS HE. Thirteen out of 14 studies reported that the presence of malnutrition was associated with increased odds of mortality following TIPS. One study reported sarcopenia as an independent predictor of liver failure, and another study reported that Pre-TIPS SMI was an independent predictor of substantial improvement in post-TIPS SMI. CONCLUSIONS: The current systematic review shows that the presence of pre-TIPS malnutrition or sarcopenia is an independent predictor of adverse outcomes after TIPS. Incorporating these parameters into present prediction models can provide additional prognostic information. ADVANCES IN KNOWLEDGE: Nutritional assessment should be part of the evaluation of patients planned for TIPS for prediction of adverse events after the procedure.

Role of Interventional Radiology (IR) in vascular emergencies among cirrhotic patients.

Gastrointestinal hemorrhage remains one of the most common causes of morbidity and mortality among patients with liver cirrhosis. Mostly, these patients bleed from the gastroesophageal varices. However, nonvariceal bleeding is also more likely to occur in these patients. Because of frequent co-existing coagulopathy, cirrhotics are more prone to bleed from a minor vascular injury while performing percutaneous interventions. Ultrasound-guided bedside vascular access is an essential procedure in liver critical care units. Transjugular portosystemic shunts (TIPS) with/without variceal embolization is a life-saving measure in patients with refractory variceal bleeding. Whenever feasible, balloon-assisted retrograde transvenous obliteration (BRTO) is an alternative to TIPS in managing gastric variceal bleeding, but without a risk of hepatic encephalopathy. In cases of failed or unfeasible endotherapy, transarterial embolization using various embolic agents remains the cornerstone therapy in patients with nonvariceal bleeding such as ruptured hepatocellular carcinoma, gastroduodenal ulcer bleeding, and procedure-related hemorrhagic complications. Among various embolic agents, N-butyl cyanoacrylate (NBCA) enables better vascular occlusion in cirrhotics, even in coagulopathy, making it a more suitable embolic agent in an expert hand. This article briefly entails the different interventional radiological procedures in vascular emergencies among patients with liver cirrhosis.