Anupam K. Kakaria

Ruptured Rudimentary Horn Pregnancy Diagnosed by Preoperative Magnetic Resonance Imaging Resulting in Fetal Salvage

Pregnancy in a rudimentary horn is very rare. The rupture of the horn during pregnancy is an obstetric emergency which can be life-threatening for both the mother and fetus. Preoperative diagnosis of such pregnancies can be challenging and they are usually diagnosed intraoperatively. We report a unique case of a 31-year-old multiparous woman who presented to the Sultan Qaboos University Hospital in Muscat, Oman, in January 2013 at 32 gestational weeks with abdominal pain. Ultrasonography was inconclusive. A rudimentary horn pregnancy was subsequently diagnosed via magnetic resonance imaging (MRI). An emergency laparotomy revealed haemoperitoneum and a ruptured rudimentary horn pregnancy. A live baby with an Apgar score of 2 at one minute and 7 at five minutes was delivered. The rudimentary horn with the placenta in situ was excised and a left salpingo-oophorectomy was performed. The postoperative period was uneventful. The authors recommend MRI as an excellent diagnostic modality to confirm rudimentary horn pregnancies and to expedite appropriate management.

Hepatic or Cystic Artery Pseudoaneurysms Following a Laparoscopic Cholecystectomy: Literature review of aetiopathogenesis, presentation, diagnosis and management

Pseudoaneurysms (PSAs) of the hepatic and/or cystic artery are a rare complication following a laparoscopic cholecystectomy (LC). Generally, PSA cases present with haemobilia several weeks following the procedure. Transarterial embolisation (TAE) is considered the optimal management approach. We report a 70-year-old woman who presented to the Sultan Qaboos University Hospital, Muscat, Oman, in 2016 with massive hemoperitoneum two weeks after undergoing a LC procedure in another hospital. She was successfully managed using coil TAE. An extensive literature review revealed 101 cases of hepatic or cystic artery PSAs following a LC procedure. Haemobilia was the main presentation (85.1%) and the mean time of postoperative presentation was 36 days. The hepatic artery was involved in most cases (88.1%), followed by the cystic artery (7.9%) and a combination of both (4.0%). Most cases were managed with TAE (72.3%), with a 94.5% success rate. The overall mortality rate was 2.0%.

Safety and Complications of Double-Lumen Tunnelled Cuffed Central Venous Dialysis Catheters Clinical and radiological perspective from a tertiary centre in Oman

OBJECTIVES This study aimed to assess the technical success, safety and immediate and delayed complications of double-lumen tunnelled cuffed central venous catheters (TVCs) at the Sultan Qaboos University Hospital (SQUH), Muscat, Oman. METHODS This retrospective study took place between January 2012 and October 2013. The clinical records and radiological data of all patients who underwent ultrasound- and fluoroscopy-guided TVC placement at SQUH during the study period were reviewed. Demographic data and information regarding catheter placement, technical success and peri- and post-procedure complications (such as catheter-related infections or thrombosis) were collected. RESULTS A total of 204 TVCs were placed in 161 patients. Of these, 68 were female (42.2%) and 93 were male (57.8%). The mean age of the patients was 54.4 ± 17.3 years. The most common reason for catheter placement was the initiation of dialysis (63.4%). A total of 203 procedures were technically successful (99.5%). The right internal jugular vein was the most common site of catheter placement (74.9%). Mild haemorrhage which resolved spontaneously occurred in 11 cases (5.4%). No other complications were observed. Subsequent follow-up data was available for 132 catheters (65.0%); of these, thrombosis-related catheter malfunction was observed in 22 cases (16.7%) and catheter-related infection in 29 cases (22.0%). CONCLUSION Radiological-guided placement of tunnelled haemodialysis catheters can be performed safely with excellent technical success. The success rate of catheter insertion at SQUH was favourable in comparison with other studies reported in the literature.

A case of postpartum choriocarcinoma: delay in diagnosis and lessons learnt.

Pregnancy related causes must always be ruled out in women with irregular vaginal bleeding in the reproductive age group even if she is postpartum and lactating. Ultrasound diagnosis of presumed incomplete miscarriage should be followed up with histology or clinically to rule out gestational trophoblastic neoplasia. We describe a woman who was treated with progestogens for irregular vaginal bleeding and eventually she was diagnosed to have stage IV choriocarcinoma.

Imaging in neuro-ophthalmology: An overview

Advances in neuroimaging and interventional techniques have revolutionized the early diagnosis, prognosis, and treatment of neuro-ophthalmic disorders. These techniques include computed tomography (CT), magnetic resonance imaging (MRI), CT and MR angiographic techniques, catheter digital subtraction angiography, functional MRI, positron emission tomography, and single photon emission computed tomography. In this review, the value of current techniques in the diagnosis, localization, and treatment of various neuro-ophthalmic disorders is described.

Different Strokes: A management dilemma.

Stroke is a common medical emergency resulting from numerous pathophysiological mechanisms and with varied clinical manifestations; as such, the diagnosis of stroke requires diligent clinical assessment. When different stroke syndromes occur in the same patient, it may cause a dilemma in terms of diagnosis and management. This continuing medical education article describes an interesting patient with recurrent neurological events, highlighting the complex pathophysiological processes associated with cerebrovascular syndromes. It offers readers the opportunity to apply their own basic neuroscience knowledge and clinical skills to solve the challenges encountered during the course of diagnosing and treating this patient. Specifically, the article aims to familiarise readers with an approach to diagnosing brainstem strokes and the diverse manifestations of a common stroke syndrome.

Lost and Found: Unusual location of a urinary tract calculus.

A 41-year-old male patient presented to the Emergency Department (ED) of Sultan Qaboos University Hospital (SQUH) complaining of left flank pain of one day’s duration which was colicky and increasing in intensity. There was no history of fever, nausea or vomiting or other significant medical history; however, a similar episode had occurred previously. The patient’s vital signs were stable and he was afebrile. Physical examination of the abdomen was non-contributory; routine microscopic urinalysis was normal. In view of the suspicion of left renal colic, he was referred for a non-contrast enhanced computed tomography (NCCT) scan, the gold standard at SQUH to assess urinary tract calculi in patients presenting with renal colic. The scan showed significant left perinephric fat stranding and mild left hydroureteronephrosis and evidence of periureteric fat stranding around the left ureter. No calculi could be identified in the left kidney or the left ureter. There was a direct inguinal hernia on the right side which contained part of the urinary bladder and a small radio-opaque calculus. These findings suggested the recent passage of a left ureteric stone into the bladder and the migration of this stone into the herniated part of the urinary bladder. It is also possible that the patient had passed out the ureteric stone via the urethra, and that the stone in the herniated bladder was an incidental finding. Clinically, the pain decreased over the period of observation in the ED, and the patient was discharged. At Urology Clinic follow-ups, there was no recurrence of pain, and the patient was managed conservatively. Inguinal hernias can be direct or indirect; the Hesselbach triangle is usually the site for direct inguinal hernias. On CT, the direct inguinal hernia lies medial to the inferior epigastric artery.1 A total of 1–3% of all inguinal hernias involve the bladder;2 in obese men aged 50–70 years, the incidence may reach 10%.3 Inguinal hernias generally occur on the right side.2 Urinary bladder hernias are mostly diagnosed incidentally during hernia surgeries,4 or during imaging.2 The herniated parts of the urinary bladder can contain tumors or calculi.2,5 These may migrate from upper tracts or form de novo in the hernia due to stasis. CT is the best modality for the diagnosis and evaluation of inguinoscrotal urinary bladder herniation after injection of intravenous contrast. The post-processing of the CT using 3D reconstructions can demonstrate the contents of the hernia and its relationships.6 Our patient’s calculus, could possibly have passed from the left ureter. However, it is possible that it may instead have travelled to the herniated component of the urinary bladder and been overlooked, especially as the herniated part of the bladder was small and did not significantly distort the urinary bladder in the pelvis. Therefore, we suggest that the protocol for the routine NCCT of the kidney, ureter and bladder for urolithiasis should extend below the pubic symphysis so as not to miss posterior urethral calculi or calculi in unusual areas.