Abstract: Objective: To record the early experience about the cerebral flow diverters (CFD) utilization and outcomes at a tertiary care hospital of Pakistan. Study design: Retrospective cohort study. Place and duration: Department of Radiology, Aga Khan University Hospital, Karachi, Pakistan. Material and methods: A retrospective review was conducted on patients who underwent CFD placement for cerebral aneurysms at our tertiary care center between 2017 and 2025. Data collected included patient demographics, aneurysm features, procedural details, and both immediate and six-month post-procedure outcomes, such as occlusion rates and any complications. The extent of aneurysm occlusion—categorized as complete or incomplete—was determined based on angiographic imaging obtained immediately following CFD deployment. Results: In a total of 27 patients, 16 (56.3%) were female and 11 (40.1%) male with mean age of 43.22 ± 17.86 years. The mean aneurysm size was calculated to be 17.87 ± 7.78 mm, whereas 22 (81.48%) were wide necked aneurysms (≥ 25 mm). Immediate post-procedural assessments displayed a 100% success rate in completing the intended procedure successfully across all 27 cases. Immediate angiogram revealed that 15 (55.56%) patients achieved complete contrast stasis/occlusion within the cerebral aneurysms, while 12 (44.4%) displayed partial contrast stasis/occlusion. In the shorter-term follow-up evaluation, 25 (92.59%) cases exhibited complete occlusion of the aneurysms with only 2 (7.41%) patients showing procedure failure, signifying a sustained positive outcome in terms of aneurysm closure. Complications were reported in 4 (4.2%) patients with 2 patients showing aneurysm wall enhancement, 1 patient showing acute thrombosis, and endoleak each. Conclusion: Despite limited resources, our center achieved good clinical outcomes, aneurysm occlusion rates, and procedural success. The occurrence of complications in a subset of cases underscores the necessity for continued refinement of patient selection criteria and procedural techniques to optimize outcomes and mitigate risks in the evolving landscape of endovascular interventions for cerebral aneurysms.

Pituitary apoplexy is a rare, life-threatening complication of pituitary macroadenomas which is often triggered by physiological stressors. It typically occurs spontaneously or may be precipitated by surgical procedures. However, occurrence after cataract surgery is exceedingly rare. A 61-year-old Pakistani hypertensive male presented with sudden-onset severe headache and projectile vomiting, 3 day post-cataract surgery. Imaging revealed a hemorrhagic pituitary macroadenoma consistent with apoplexy. Neurologic examination was normal. The patient was managed conservatively with corticosteroids, fluids, and pituitary hormone replacement therapy. He improved clinically, and follow-up MRI revealed interval reduction in lesion size and improvement in radiologic features. This case highlights cataract surgery as a potential trigger for pituitary apoplexy in predisposed individuals. The absence of focal neurologic deficits poses a diagnostic challenge. Early recognition, neuroimaging, and endocrine support are critical for optimal outcomes. Awareness of this association can aid in timely diagnosis and management in postoperative patients with unexplained symptoms.

In Duodenum Inversum (DI), the third part of the duodenum follows a superior, posterior course before crossing over the midline above the pancreas. A 35-year-old female presented with right upper quadrant (RUQ) pain for the last 2 months. The patient did not have any other medical conditions and had visited multiple hospitals for treatment of the RUQ pain. Upon abdominal examination, tenderness was noted in RUQ, leading to initial suspicions of costochondritis and cutaneous nerve inflammation. Symptoms were resolved with neuromodulator drug, Pregablin. A CT scan was then carried out, revealing incidental findings consistent with the Duodenum Inversum. This case report describes an incidental finding of Duodenum Inversum and an updated literature review, including 17 articles covering diagnostic procedures, treatment modalities, and associated complications.

Hepatocellular Carcinoma (HCC) accounts for the sixth most common cancer, implying considerable disease burden. Liver Ultrasound (US) and the use of certain serum biomarkers, like Alpha-Feto Protein (AFP) and Protein induced by vitamin K absence or antagonist II (PIVKA-Ⅱ) have gained popularity over time as screening methods for the detection of HCC. AFP is beneficial when used in combination with US or PIVKA-II to increase the validity of results and for smaller tumors (≤ 2 cm) to be detected. The objective of this article is to recognize and address the growing role and potential of Interventional Radiology (IR) as a diagnostic and therapeutic field for the treatment of HCC. The use of contrast-enhanced CT or MRI has continued to gain popularity as a non-invasive yet accurate diagnostic tool. This paper also highlights the scope of newer treatment strategies adopted by Interventional Radiologists for HCC. Some key IR therapies include Radiofrequency Ablation (RFA), Transarterial Chemoembolization (TACE), and Transarterial Radioembolization (TARE) which are applied more efficiently due to the 2022 updated Barcelona Clinic Liver Cancer (BCLC) staging criteria that guide Interventional Radiologists to decide on a treatment strategy specific to the stage and each patient’s unique medical history, enhancing patient care for liver cancer patients. However, there is a need for more research in the field and for an internationally agreed consensus to set out guidelines regarding screening protocol for detection of HCC and predicting response to treatment.

Background and Objective: A large number of review and research articles exists in literature which describe the radiological appearance of various manifestations of nervous system tuberculosis, however there is paucity of text which describes the application of each and every imaging modality in the workup of the entire spectrum of this pathology. The intent of this article is to review the existing literature on the role of different radiological modalities in the stepwise work up of CNS TB. The article focuses on the role of plain radiograph, fluoroscopy, computed tomography, magnetic resonance imaging along with its advanced sequences and nuclear medicine in imaging of the many faces of tuberculosis in CNS. The article also aims to review the existing literature on the role of MR based textural analysis (Radiomics) as a problem-solving tool in various nervous system pathologies. Methods: We searched PubMed central databases for articles published in English from January 1 2000 to February 28 2021 along with references from the relevant articles. The search terms included “imaging in central nervous system tuberculosis” “Radiomics in tuberculosis “, “Radomics in central nervous system ”. In total 95 articles including case reports, case series, original articles and review articles were included in this review. Results: Conventional imaging modalities including radiograph and fluoroscopy are becoming extinct in work up of tuberculosis in the nervous system itself, however a plain radiograph still holds a key position in screening the chest for presence of subclinical respiratory tract infection in patients presenting with brain tuberculosis. In addition, it is a sensitive tool as baseline investigation in workup of spinal tuberculosis (T.B). Fluoroscopy is a useful tool in image guided procedures for collection of samples for histopathology and CSF analysis. Cross sectional imaging modalities including computed tomography and magnetic resonance imaging have revolutionized imaging of central nervous system pathologies in particular tuberculosis. Computed tomography acts as a screening tool to identify the presence of intracranial tuberculosis and recognize its complications. In addition it is an important tool to determine the extent of spinal T.B. Magnetic Resonance Imaging (MRI) along with its advanced sequences including spectroscopy, Magnetization transfer T1 sequence (MT T1), perfusion imaging, and magnetic resonance angiography (MRA) and magnetic resonance venography (MRV) is an ideal imaging method to work up CNS TB. It can identify numerous manifestations of tuberculosis in the brain, work up its associated complication, and explain the extent of neurological symptoms. Moreover, it has the capability to differentiate TB from other nervous system infections. Furthermore, it can differentiate neoplastic and inflammatory brain disorders from CNS TB. Radiomics, particularly the textural features based on MR imaging is the future of neuroimaging. Its role is getting established in the work up of several intracranial pathologies including brain tumors and neurodegenerative disorders. Certainly, it has significant potential in the imaging work up of CNS tuberculosis, which is underexplored and therefore requires the central attention of upcoming researchers focusing on this topic. Conclusion: Cross sectional imaging is the mainstay of imaging workup. Nuclear imaging is becoming an essential adjuvant to determine the burden of the disease. Role of radiomics is evolving in intracranial pathologies and certainly needs the central attention of future researches to establish its role in CNS TB imaging.

INTRODUCTION:Patients receiving renal transplants have weakened immune systems and are more vulnerable to lung infections. OBJECTIVES:To determine the diagnostic accuracy of high-resolution computed tomography (HRCT) in detecting pneumocystis carinii in renal transplant patients presenting with pulmonary infection in a tertiary care transplant center, keeping bronchoalveolar lavage (BAL) as the gold standard. METHODS:This cross-sectional study was conducted at the Department of Radiology, Sindh Institute of Urology and Transplant, Karachi, from February 14, 2023, to August 13, 2023. Using a non-probability consecutive sampling technique, we enrolled 81 post-renal transplant patients, aged 20 to 60 years, of both genders, who were receiving immunosuppressive therapy and referred to the Radiology Department for HRCT as part of a workup for pulmonary infection. Patients presented with pulmonary infection underwent HRCT and BAL. Diagnostic accuracy was determined and data was analyzed. RESULTS:In this study, 81 patients were enrolled with a mean age of 35.4±11.3 years. There were 56 (69.1%) male and 25 (30.9%) female patients. The mean duration of renal transplant was 18.09±12.8 months. The mean duration of symptoms was 5.32±2 days. Diabetes was present in 43 (53.1%) patients. The sensitivity of HRCT in diagnosing pneumocystis carinii was 93%, specificity was 91.7%, positive predictive value was 96.4%, negative predictive value was 84.6%, and diagnostic accuracy was 92.5%, taking BAL as the gold standard. CONCLUSION:HRCT is a good imaging modality to diagnose pneumocystis carinii in renal transplant patients.

Objective: To determine the frequency and extent of artefacts in magnetic resonance imaging and/or computed tomography scans of head caused by fixed dental prosthesis. Method: The retrospective study was conducted at Aga Khan University Hospital from July to December 2021, and comprised magnetic resonance imaging and/or computed tomography scans from January 2015 to December 2020 of the head of individuals with existing fixed dental prosthetic work at the time of exposure. They were analysed for the presence of artefacts. The association between artefacts and the presence of fixed dental prosthesis was explored. Data was analysed using SPSS 23. Results: Of the 297 images evaluated, 173 (58%) were magnetic resonance imaging scans, and 124(42%) were computed tomography scans. The most common artefacts was grade I 148(49.8%), followed by grade II 140(47.1%) and grade III 9(3%). There was no significant association between fixed dental prosthesis and the artefacts (p>0.05). Conclusion: There should be no reservations in placing fixed metal prosthesis in individuals on account of future brain scans. Key Words: Fixed dental prosthesis, Imaging, CT scan, MRI, OPG, Artefacts.

A consensus meeting of national experts from all major national hepatobiliary centres in the country was held on May 26, 2023, at the Pakistan Kidney and Liver Institute & Research Centre (PKLI & RC) after initial consultations with the experts. The Pakistan Society for the Study of Liver Diseases (PSSLD) and PKLI & RC jointly organised this meeting. This effort was based on a comprehensive literature review to establish national practice guidelines for hilar cholangiocarcinoma (hCCA). The consensus was that hCCA is a complex disease and requires a multidisciplinary team approach to best manage these patients. This coordinated effort can minimise delays and give patients a chance for curative treatment and effective palliation. The diagnostic and staging workup includes high-quality computed tomography, magnetic resonance imaging, and magnetic resonance cholangiopancreatography. Brush cytology or biopsy utilizing endoscopic retrograde cholangiopancreatography is a mainstay for diagnosis. However, histopathologic confirmation is not always required before resection. Endoscopic ultrasound with fine needle aspiration of regional lymph nodes and positron emission tomography scan are valuable adjuncts for staging. The only curative treatment is the surgical resection of the biliary tree based on the Bismuth-Corlette classification. Selected patients with unresectable hCCA can be considered for liver transplantation. Adjuvant chemotherapy should be offered to patients with a high risk of recurrence. The use of preoperative biliary drainage and the need for portal vein embolisation should be based on local multidisciplinary discussions. Patients with acute cholangitis can be drained with endoscopic or percutaneous biliary drainage. Palliative chemotherapy with cisplatin and gemcitabine has shown improved survival in patients with irresectable and recurrent hCCA.

Objectives This study aimed to retrospectively review imaging findings and the outcomes of uterine artery embolisation (UAE) in symptomatic uterine vascular anomalies (UVA). Methods This study included a total of 15 patients with acquired UVA admitted to the Aga Khan University Hospital in Karachi, Pakistan, from 2010 to 2020. These patients were evaluated using ultrasound, computed tomography and magnetic resonance imaging, either alone or in combination. All patients had a history of dilatation and curettage or uterine instrumentation and underwent angiography and embolisation of the uterine arteries. The primary outcome post embolisation was assessed clinically and/or in combination with ultrasound. Post-procedure pregnancies were also recorded. Results Non-invasive imaging was abnormal in all patients; however, this pre-intervention imaging was unable to accurately classify the type of vascular anomaly, except in the case of a pseudoaneurysm. Conventional angiography showed uterine artery hyperaemia in six patients, arteriovenous malformation in seven patients and pseudoaneurysm in two patients. The technical success rate was 100% and no repeat embolisation was needed. The follow-up ultrasound in 12 patients revealed a resolution of the abnormal findings, while the remaining three were found to be normal on clinical follow-up. Seven patients (46.7%) had a normal pregnancy 15.7 months after the procedure (range: 4–28 months). Conclusions UAE is a safe and effective management option for intractable severe bleeding in patients with UVA post instrumentation and it was found that the procedure does not impair future pregnancy.

Background and objective: MR based radiomics can potentially response to treatment in intracranial tuberculoma, but very scarce literature is available in this regard. The purpose of this study was to determine whether MR based radiomic features can be used to predict response to antituberculosis (AT) treatment. Methods: Data of patients with intracranial tuberculomas who underwent MR imaging and AT treatment at our institution during the last 10 years was analyzed. In each case follow-up imaging performed at 6 months post initiation of treatment was reviewed to establish response to treatment. The textural analysis was performed by two consultant neuroradiologists, using open-source software (Lifex) with FLAIR coronal image after contrast administration from pretreatment MRI study radiomic analysis. Results: Twenty-four patients with mean age 33.8 years were included in the study. Sixteen patients were in the treatment responsive group while eight patients were in the treatment resistant group. Thirty-eight radiomic parameters were extracted for each patient. There was a significant difference in three out of 38 parameters (histogram skewness, GLCM correlation and NGLDM Coarseness) in patients amongst the two groups. Logistic regression model was developed using these parameters which accurately predicted 83.3% of the cases according to the response to the AT treatment (χ2=11.517, p=0.003). ROC curve analysis was performed using histogram skewness which showed acceptable discrimination (p=0.037 and 95% CI =0.577-0.954) for predicting the response to treatment. Conclusion: MR textural parameters (histogram skewness, GLCM correlation and NGLDM Coarseness) may be used as imaging biomarkers to predict response to treatment in patients with intracranial tuberculoma.

Pulmonary arteriovenous malformation (PAVMs) are abnormal communications between pulmonary arteries and veins. The rarity of their occurrence, coupled with the risks they pose, including brain abscess, embolic stroke, and myocardial infarction, mandates that they should not be overlooked in the differential diagnosis of patients presenting with haemoptysis, dyspnea, clubbing, cyanosis, hypoxemia, or epistaxis. We present the case of a 41-year-old local female who presented to our hospital as an outpatient with decreased oxygen saturation (SpO2) of 70%-80% for the past two years with a final diagnosis of PAVM. The initial baseline workup showed polycythemia with a hemoglobin level of 19 mg/dL and raised hematocrit. She had extensive workup in the past two years for her polycythemia including gene mutation testing and cardiac workup which all turned out normal. Her chest X-ray (CXR) showed right lung opacity which was initially considered to be infective but it did not respond to antibiotic treatment. Later on, a CT scan of the chest was performed and findings were typical of a large PAVM which had two feeding arteries. The patient was referred to a cardiothoracic surgeon who sent the patient to the interventional radiology section for endovascular management. The embolization procedure was then performed and both feeders were successfully embolised. After the procedure, the patient's SpO2 levels were restored to 95%-96%, and no post-procedure complications were noted.

OBJECTIVE:To analyse the size and morphology of the normal pineal gland in the paediatric age group using magnetic resonance imaging. METHODS:The retrospective study was conducted at the Aga Khan University Hospital, Karachi, and comprised data of patients aged <18 years who had magnetic resonance imaging done between 2007 and 2017. Pineal size was estimated measuring its largest anteroposterior and supero-inferior diameters on sagittal T2-weighted sequences on any slice with maximal diameter. The width of pineal gland was measured on axial or coronal T2 sequences. The volume, morphology and enhancement patterns of the gland were also assessed. Data was analysed using SPSS 21. RESULTS:Of the 200 patients, 116(58%) were males and 84(42%) were females. The overall mean age was 7.8±5.5 years. The mean anteroposterior dimension was 4.85±1.46mm, height 3.31±0.95mm, width 4.16±1.19, and volume 39.54±38.12 mm3. Mean size of cyst was 2.77±1.4mm (range: 1.2-7.5mm). No significant differences in the pattern of enhancement were found in different age groups (p>0.05). CONCLUSIONS:Comprehensive knowledge of the size of the typical pineal organ is useful for radiologists in the identification of pineal gland anomalies and the exclusion of neoplastic lesions.

16 Objective: To retrospectively review imaging findings and the outcomes of uterine artery 17 embolization (UAE) in symptomatic uterine vascular anomalies. Methods: We identified 15 18 cases of acquired uterine vascular anomaly from 2010 to 2020 who were evaluated with 19 ultrasound, computed tomography, and magnetic resonance imaging, either alone or in 20 combination. All patients had history of dilatation and curettage or uterine instrumentation. They 21 underwent angiography and embolization of the uterine arteries. Primary outcome post 22 embolization was assessed clinically and/or in combination with ultrasound. Post procedure 23 pregnancies were also recorded. Results: Non-invasive imaging was abnormal in all patients, 24 however this pre intervention imaging was unable to accurately classify the type of vascular 25 anomaly except in the case of pseudoaneurysm. Conventional angiography showed uterine artery 26 hyperemia in 6, arteriovenous malformation in 7 and pseudoaneurysm in 2 patients. The 27 technical success rate was 100% with no repeat embolization needed. Follow up ultrasound in 12 28 patients revealed resolution of abnormal findings, remaining three were normal on clinical 29 follow up. Seven patients (46.7%) had a normal pregnancy, 15.7 months after the procedure 30 (range 4-28 months). Conclusion: UAE is a safe and effective management option for intractable 31 severe bleeding in patients with uterine vascular anomaly post instrumentation and is seen not to 32 impair future pregnancy. 33

Objective: To share experience and present our data of past 15 years on endoscopy guided empiric embolization of GDA and compare it with the results of conservative management. Study Design: Retrospective study Setting: Agha Khan University Hospital Karachi. Period: January 2001 till October 2017. Material & Methods: 70 patients were selected who presented with upper GI bleed followed by conventional angiography. The data was collected on clinical presentation, patient demographics, embolization procedures, and postembolization outcomes. Results: A total of 101 patients were included in the study. 79 were male and 22 were female. The median age at presentation was 54 years (range 15-96 years). All the patients presented with upper gastrointestinal bleeding. All the patients underwent fluoroscopy guided angiography. In 30 patients the angiography was able to locate the bleeding source. In 44 patients the bleeding source could not be identified however empiric embolization was performed. In 27 patients the angiography was negative and embolization was not performed. The overall clinical success in the empirically embolized group is 77.2 %. 27 patients were conservatively managed after negative angiography. The overall clinical success in the empirically embolized group is 77.2 %.However in the patients who were conservatively managed the clinical success was only 48.1 %. Conclusion: This study concluded that it safe and effective to empirically emobolize the GDA in patients refractory to initial endoscopic treatment for non variceal upper GI bleed.

Fracture and migration of port-a-catheter, following long term access into the central venous vasculature is a rare clinical scenario. The consequences of fracture and migration includes fragmented device relocating into the right atrium or ventricle, eventually causing life threatening complications such as arrhythmias, pseudoaneurysms, perforations or very rarely embolization. We report a case of a 67-year-old female with a broken port-a-catheter which had been placed initially for chemotherapy for bilateral breast cancer. Chest radiograph showed the fragmented catheter had migrated to the right atrium; which was successfully removed via percutaneous radiological endovascular intervention. No immediate post procedure complication was noted.

Radiology request forms are the basis of communication between referring physicians and radiologists. These are the sole documents on the basis of which a justification to carry out a radiological procedure is carried out. However, across the globe, there is a problem of inadequately filled radiology request forms. Several interventions like standardization and the use of technology have been proposed worldwide to overcome the shortcomings of inadequately filled radiology request forms. We carried out a two-phase audit assessing the impact of a technological intervention on the quality of radiology requests with the results showing marked improvement in key parameters. A subset analysis was also done to highlight the importance of radiology request forms by following the patients' treatment course. The remaining shortcomings highlight the importance of training sessions and refresher courses for junior doctors in order to familiarize them with the importance of adequately filled radiology request forms.

Pseudo-aneurysm of internal maxillary artery, following a road traffic accident, is a rare clinical scenario. The consequence of pseudo-aneurysm may be spontaneous rupture of the arterial wall, which may eventually lead to life-threatening hemorrhage. We report a case of a 20-year male who presented with recurrent epistaxis. CT scan was performed, which revealed a pseudo-aneurysm of the internal maxillary artery; this was successfully treated by angioembolisation. Similar cases of traumatic pseudo-aneurysms have been reported, however, none presented with recurrent epistaxis after management of pan-facial fractures.

Management of endogenous Cushing syndrome is based on its aetiology. Increased Adrenocorticotropic Hormone (ACTH) levels are the most common cause of this disorder and, therefore, it is critical to determine the source of ACTH before further management. Dynamic post contrast MRI is currently the most common investigation implied to diagnose pituitary adenoma; however, it comes with the drawback of low specificity and high false positive results. Inferior petrosal sinus sampling (IPSS) is an established invasive procedure performed to differentiate central versus peripheral source of ACTH which, in turn, results in hypercortesolaemia. This is a series of 14 patients who underwent IPSS at the Department of Radiology, Aga Khan University Hospital, Karachi, from January 2006 to December 2018. The case series emphasises the role of IPSS in the management of ACTH-dependent Cushing syndrome and combined efficacy of Dynamic post-contrast MRI and the procedure under focus.

Introduction Acute right lower quadrant abdominal pain is one of the most common surgical presentations to the emergency department with acute appendicitis being the topmost differential diagnosis. Although computed tomography (CT) is the gold standard in diagnosing appendicitis, in our setup ultrasound is often the initial imaging modality available in urgent care settings especially for children and pregnant females. On ultrasound, an inflamed appendix has a diameter of 6 mm or more and is non-compressible. Increased periappendiceal fat echogenicity is an important ancillary sign of acute appendicitis that supports the sonographic diagnosis of acute appendicitis. To determine the association of periappendiceal fat echo sign (PFES) on ultrasound in surgically proven cases of acute appendicitis. Methods This cross-sectional study was held at the Department of Radiology at the Aga Khan University Hospital in Karachi, Pakistan. Periappendiceal fat echogenicity was assessed and prospectively graded in 59 patients. These patients had sonographic features of acute appendicitis which was later confirmed by surgery. Data were collected on a proforma and later analyzed. Frequency of increased periappendiceal fat echogenicity in acute appendicitis was calculated. Association of PFES with gender and ascites was evaluated with Fischer's exact test and with patient's age and appendiceal diameter was assessed using analysis of variance (ANOVA). Results Increased periappendiceal fat echogenicity was seen in 89.8% of patients with acute appendicitis. 10.2% of patients had acute appendicitis with normal surrounding fat. Mean appendiceal diameter in patients with grade 3 PFES was significantly more than those with grade 2 or grade 1 PFES. PFES had no association with age and gender of the patient or with ascites. Conclusion Increased periappendiceal fat echogenicity is an important ancillary sign of acute appendicitis that helps support its sonographic diagnosis.