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1.  Bladder stones – red herring for resurgence of spasticity in a spinal cord injury patient with implantation of Medtronic Synchromed pump for intrathecal delivery of baclofen – a case report 
BMC Urology  2003;3:3.
Increased spasms in spinal cord injury (SCI) patients, whose spasticity was previously well controlled with intrathecal baclofen therapy, are due to (in order of frequency) drug tolerance, increased stimulus, low reservoir volume, catheter malfunction, disease progression, human error, and pump mechanical failure. We present a SCI patient, in whom bladder calculi acted as red herring for increased spasticity whereas the real cause was spontaneous extrusion of catheter from intrathecal space.
Case Presentation
A 44-year-old male sustained a fracture of C5/6 and incomplete tetraplegia at C-8 level. Medtronic Synchromed pump for intrathecal baclofen therapy was implanted 13 months later to control severe spasticity. The tip of catheter was placed at T-10 level. The initial dose of baclofen was 300 micrograms/day of baclofen, administered by a simple continuous infusion. During a nine-month period, he required increasing doses of baclofen (875 micrograms/day) to control spasticity. X-ray of abdomen showed multiple radio opaque shadows in the region of urinary bladder. No malfunction of the pump was detected. Therefore, increased spasticity was attributed to bladder stones. Electrohydraulic lithotripsy of bladder stones was carried out successfully. Even after removal of bladder stones, this patient required further increases in the dose of intrathecal baclofen (950, 1050, 1200 and then 1300 micrograms/day). Careful evaluation of pump-catheter system revealed that the catheter had extruded spontaneously and was lying in the paraspinal space at L-4, where the catheter had been anchored before it entered the subarachnoid space. A new catheter was passed into the subarachnoid space and the tip of catheter was located at T-8 level. The dose of intrathecal baclofen was decreased to 300 micrograms/day.
Vesical calculi acted as red herring for resurgence of spasticity. The real cause for increased spasms was spontaneous extrusion of whole length of catheter from subarachnoid space. Repeated bending forwards and straightening of torso for pressure relief and during transfers from wheel chair probably contributed to spontaneous extrusion of catheter from spinal canal in this patient.
PMCID: PMC155678  PMID: 12659647
2.  Intrathecal baclofen withdrawal syndrome- a life-threatening complication of baclofen pump: A case report 
Intrathecal baclofen pump has been used effectively with increasing frequency in patients with severe spasticity, particularly for those patients who are unresponsive to conservative pharmacotherapy or develop intolerable side effects at therapeutic doses of oral baclofen. Drowsiness, nausea, headache, muscle weakness, light-headedness and return of pretreatment spasticity can be caused by intrathecal pump delivering an incorrect dose of baclofen. Intrathecal baclofen withdrawal syndrome is a very rare, potentially life-threatening complication of baclofen pump caused by an abrupt cessation of intrathecal baclofen.
Case presentation
A 24-year-old man with a past medical history of cerebral palsy and spastic quadriparesis developed hyperthermia, disseminated intravascular coagulation, rhabdomyolysis, acute renal failure and multisystem organ failure leading to a full-blown intrathecal baclofen withdrawal syndrome. Intrathecal baclofen pump analysis revealed that it was stopped due to some programming error. He was treated effectively with supportive care, high-dose benzodiazepines and reinstitution of baclofen pump.
The episodes of intrathecal baclofen withdrawal syndrome are mostly caused by preventable human errors or pump malfunction. Educating patients and their caregivers about the syndrome, and regular check-up of baclofen pump may decrease the incidence of intrathecal baclofen withdrawal syndrome. Oral baclofen replacement may not be an effective method to treat or prevent intrathecal baclofen withdrawal syndrome. Management includes an early recognition of syndrome, proper intensive care management, high-dose benzodiazepines and prompt analysis of intrathecal pump with reinstitution of baclofen.
PMCID: PMC514562  PMID: 15301690
3.  Management of severe spasticity with intrathecal baclofen delivered by a manually operated pump. 
Intrathecal baclofen abolishes spasticity in many patients with neurological diseases but there are few studies on its long-term effectiveness. Since 1986 a manually operated subcutaneous pump has been used to deliver baclofen intrathecally in 21 patients with a follow up of at least one year. Most patients had multiple sclerosis and all were wheelchair-bound. Sixteen patients had a complete and sustained benefit. In four other patients the treatment was effective in the short term but not in the long term. In the remaining patient the pump never worked. Complications included meningitis, pump failure, erosion through the skin, and baclofen overdose. Nevertheless, only three patients have asked to discontinue the treatment. We conclude that intrathecal baclofen, delivered by a manually operated implanted pump, is an effective treatment for severe spasticity in most patients.
PMCID: PMC1072919  PMID: 8201328
4.  Complications of Intrathecal Baclofen Pump: Prevention and Cure 
ISRN Neurology  2012;2012:575168.
Increasingly, spasticity is managed with surgically implanted Intrathecal Baclofen pumps. Intrathecal Baclofen pump revision surgery unrelated to programmable pump end-of-life is not uncommon, requiring special attention during pre-, intra-, and postoperative management. We aimed to identify and describe complications of Intrathecal Baclofen pump as well as to report avoidance and management of complications. Methods and Materials. Through 2002–2006, at the department of neurosurgery, Henry Ford and Oakwood Health Systems, Intrathecal Baclofen pumps were implanted in 44 patients: 24 children versus 20 adults; 30 “primary-implant-patients”; 14 “revision-only patients”. We evaluated reasons for revision surgeries and diagnostic workup requirements. Results. Eight primary-implant-patients required 14 revisions and 7 of revision-only patients needed 13 procedures. Seven patients with slowly increasing baclofen-resistant spasticity had either (i) unsuspected pump-catheter connector defects, (ii) an X-ray-documented pump-catheter connector defect, (iii) X-ray-demonstrated fractured catheter with intrathecal fragment. Implant infections occurred in 4 cases. Scintigraphy revealed occult CSF leakage N=1 and intrinsic pump failure N=1. Conclusion. Intrathecal Baclofen pumps, although very gratifying, have a high, technique-related complication incidence during implant life. Meticulous technique, high clinical suspicion, appropriate workup, and timely surgical management can reduce surgical complications of Intrathecal Baclofen pump implantation.
PMCID: PMC3323842  PMID: 22548189
5.  Unpredicted spontaneous extrusion of a renal calculus in an adult male with spina bifida and paraplegia: report of a misdiagnosis. Measures to be taken to reduce urological errors in spinal cord injury patients 
BMC Urology  2001;1:3.
A delay in diagnosis or a misdiagnosis may occur in patients with spinal cord injury (SCI) or spinal bifida as typical symptoms of a clinical condition may be absent because of their neurological impairment.
Case presentation
A 29-year old male, who was born with spina bifida and hydrocephalus, became unwell and developed a swelling and large red mark in his left loin eighteen months ago. Pyonephrosis or perinephric abscess was suspected. X-ray of the abdomen showed left-sided staghorn calculus. Since ultrasound scan showed no features of pyonephrosis or perinephric abscess, he was prescribed a prolonged course of antibiotics for infection presumed to arise from the site of metal implant in spine. He developed a discharging sinus, following which the loin swelling and red mark subsided. About three months ago, he again developed a red mark and minimal swelling in the left loin. Ultrasound scan detected no abnormality in the renal or perinephric region. Therefore, the red mark and swelling were attributed to pressure from the backrest of his chair. Five weeks later, the swelling in the left loin burst open and a large stone was extruded spontaneously. An X-ray of the abdomen showed that he had extruded the central portion of the staghorn calculus from left kidney. With hindsight, the extruded renal calculus could be seen lying in the subcutaneous tissue of left loin lateral to the 10th rib in the X-ray of abdomen, which was taken when he presented with red mark and minimal swelling.
This case illustrates how mistakes in diagnosis could occur in spinal cord injury patients, and highlights the need for corrective measures to reduce urological errors in these patients. Voluntary reporting of urological errors is recommended to facilitate learning from our mistakes. In the patients who have marked spinal curvature, ultrasonography of kidneys and perinephric region may not be entirely reliable. As clinical symptoms and signs may be non-specific in SCI patients, they require prompt, detailed and occasionally, repeated investigations. A joint team approach by health professionals belonging to various medical disciplines, which is strengthened by frequent, informal and honest discussions of a patient's clinical condition, is likely to reduce urological errors in SCI patients.
PMCID: PMC64578  PMID: 11801198
6.  Abcès rénal et périrénal chez l'enfant. 
One child with a pure perinephric abscess and three with renal abscesses, one of which had perinephric extension, are described. All presented with a long course of subacute infection leading to localizing symptoms or signs in the flank. The diagnosis was confirmed by radiologic examination. All the abscesses were surgically drained at various intervals after diagnosis, while the patients were receiving antibiotic therapy. Salvage of renal function was possible in all cases. A rational approach to the diagnosis and management of such abscesses is emphasized.
PMCID: PMC1704284  PMID: 519594
7.  Diagnosis and treatment of giant lateral abdominal wall haematoma after blunt trauma: a case report 
Cases Journal  2009;2:9358.
Lateral abdominal wall haematoma after blunt trauma that require surgery is rare. They usually present with pain, bruising and swelling after trauma.
We report a case of a fit and healthy young girl who developed a large lateral abdominal wall haematoma following blunt trauma. Initially the haematoma was managed conservatively, however in view of increasing size surgical removal was undertaken. Post operatively the patient developed a small seroma and which was subsequently drained under ultrasound guidance. A thorough review of the literature has identified there are various options of treatment for patients with lateral abdominal wall haematoma. We conclude that management of giant traumatic lateral abdominal wall haematoma can be challenging, some will eventually need surgical intervention.
PMCID: PMC2804729  PMID: 20066065
8.  Renal lymphangiectasia presented by pleural effusion and ascites 
A young male patient complaining of vague abdominal pain, dyspnea, generalized weakness and abdominal distension for 6 months was referred for abdominal ultrasound. Ultrasound showed enlarged echogenic kidneys, perinephric and renal sinus cystic fluid collections bilaterally with ascites and right pleural effusion. The ultrasound findings were confirmed by abdomen CT scan. Renal function test was within normal. Laboratory analysis of aspirated perinephric fluid revealed abundant lymphocytes. The radiological findings and perinephric fluid aspiration analysis are consistent with renal lymphangiectasia. Pleural effusion, in addition to ascites and perinephric fluid collections, is a new presentation of the disease. Ascites and pleural effusion were improved by diuretics.
PMCID: PMC3303272  PMID: 22470619
Renal; lymphatic; cysts; pleural effusion; ascites; renal lymphangiectasia
9.  Intrathecal baclofen: Its effect on symptoms and activities of daily living in severe spasticity due to spinal cord injuries: A pilot study 
Indian Journal of Orthopaedics  2009;43(1):46-49.
Spasticity is a major problem related to spinal cord injuries. Use of intrathecal baclofen with an implanted pump seems a very useful mode of therapy in patients in whom oral antispasmodic agents are either not effective or produce intolerable side-effects.
Materials and Methods:
Twenty-four patients with mean age 50 years (range 32-72 years) had intrathecal baclofen pump implanted for the severe spasticity of spinal origin. One patient died following implantation of pump due to natural causes and was not included in the study. The patients were followed up for mean 22 months (range, one to five years).
All 24 patients showed improvement in their spasm following the procedure. Improvement was noted in pain (12), sleep disturbance (20) and sphincter control (14). Patients had improvement in activities of daily living such as feeding ability (10), self care (10), indoor and outdoor mobility (19), and driving (4). One patient had catheter leakage immediately after the surgery and required change of catheter. The radio telemetry allows very good adjustment of the dose according the individual patients needs.
Intrathecal baclofen pump improves the symptoms of spasm and also the quality of life. It helps the patient to live more independently. It is not an irreversible surgery for the patient and hence it is very useful in the changing the dynamics in this group of patients.
PMCID: PMC2739492  PMID: 19753179
Activities of daily living; intrathecal baclofen; spasticity; spinal cord injury
10.  Should breast biopsy cavities be drained? 
A total of 112 women was entered into a randomised study to investigate the effects of suction drainage on haematoma formation in breast biopsy wounds. Of 107 evaluable patients, 52 received drainage and 55 had no drain. The wounds were examined 1 week after operation when the volume of wound haematoma was measured using ultrasonography. Haematomas were present in 48 (87%) patients with undrained wounds compared with 34 (65%) patients with drained wounds (P = 0.014, chi 2 test). Median haematoma volume was 20 ml (range 0-172.5 ml) in the undrained group compared with 2 ml (range 0-100 ml) in the drained group (P = 0.001, Mann-Whitney U test). There was one wound infection in each group. There was no difference in median pain score or duration of pain between the groups. While suction drainage significantly reduces the incidence and volume of wound haematomas, this does not appear to influence outcome.
PMCID: PMC2502159  PMID: 8117018
11.  Intrathecal baclofen therapy in severe head injury, first time in Nepal, a technique suitable for underdeveloped countries 
Asian Journal of Neurosurgery  2011;6(1):49-51.
Intrathecal baclofen (ITB) has been found to be helpful not only for spasticity but also for unconsciousness in a vegetative patient. This is the first case of ITB in Nepal, and here we discuss the effectiveness of ITB for spasticity in a patient in vegetative state. We also discuss about a simple technique for ITB used in Nepal where baclofen pump is not available. Here, we present a case of a 40-year-old male patient who had severe head injury with diffuse axonal injury treated conservatively. He went on to a vegetative state and subsequently developed severe spasticity of all the limbs. ITB was started under the guidance of one of the authors , Prof. Taira. Baclofen was injected to the spinal intrathecal space through a catheter which is used for spinal anesthesia. Spasticity improved significantly and his higher mental function also showed signs of improvement. He finally became fully conscious and well oriented. ITB is very useful in cases of severe spasticity and vegetative condition, a state of unconsciousness lasting longer than a few weeks. Even with a simple technique in the absence of baclofen pump, ITB can be used with its optimum effect.
PMCID: PMC3205552  PMID: 22059105
Intrathecal baclofen; Nepal; spasticity; vegetative state
12.  Effect of intrathecal baclofen delivered by an implanted programmable pump on health related quality of life in patients with severe spasticity 
OBJECTIVES—To compare clinical effectiveness and health related quality of life in patients with severe spasticity who received intrathecal baclofen or a placebo.
METHODS—In a double blind, randomised, multicentre trial 22 patients were followed up during 13 weeks and subsequently included in a 52 week observational longitudinal study. Patients were those with chronic, disabling spasticity who did not respond to maximum doses of oral baclofen, dantrolene, and tizanidine. After implantation of a programmable pump patients were randomly assigned to placebo or baclofen infusion for 13 weeks. After 13 weeks all patients received baclofen. Clinical efficacy was assessed by the Ashworth scale, spasm score, and self reported pain, and health related quality of life by the sickness impact profile (SIP) and the Hopkins symptom checklist (HSCL).
RESULTS—At three months the scores of the placebo and baclofen group differed slightly for the spasm score (effect size=0.20) and substantially for the Ashworth scale (effect size=1.40) and pain score (effect size=0.94); health related quality of life showed no significant differences. Three months after implantation the baclofen group showed a significant, substantial improvement on the SIP "physical health", "mental health", "mobility", and "sleep and rest" subscales and on the HSCL mental health scale; patients receiving placebo showed no change. After one year of baclofen treatment significant (P<0.05) improvement was found on the SIP dimensions "mobility" and "body care and movement" with moderate effect sizes. Improvement on the SIP subscale "physical health" (P<0.05; effect size 0.86), the SIP overall score (without "ambulation"), and the "physical health" and overall scale of the HSCL was also significant, with effect sizes >0.80. Changes in health related behaviour were noted for "sleep and rest" and "recreation and pastimes" (P<0.01, P<0.05; effect size 0.95 and 0.63, respectively). Psychosocial behaviour showed no improvement.
CONCLUSIONS—Intrathecal baclofen delivered by an implanted, programmable pump resulted in improved self reported quality of life as assessed by the SIP, and HSCL physical health dimensions also suggest improvement.

PMCID: PMC2169658  PMID: 9285459
13.  Baclofen Pump Intervention for Spasticity Affecting Pulmonary Function 
Muscle spasticity may adversely affect pulmonary function after spinal cord injury (SCI). However, there is limited information regarding the treatment of spasticity as a determinant of pulmonary function. This study presents the case of a man with C4 tetraplegia who had severe spasticity and difficulty weaning from ventilatory support.
Case presentation.
Severe spasticity likely contributed to respiratory compromise in this patient. Successful and rapid weaning from the ventilator occurred within 3 weeks of baclofen pump placement.
Randomized clinical trials among SCI patients with significant spasticity are needed to determine whether intervention with a baclofen pump facilitates earlier ventilatory weaning.
PMCID: PMC1864906  PMID: 16396387
Spinal cord injuries; Spasticity; Ventilator weaning; Baclofen pump; Respiratory impairment; Tetraplegia
14.  Perinephric and Intranephric Abscesses: A Review of the Literature 
Western Journal of Medicine  1982;136(2):95-102.
Perinephric and intranephric (renal cortical and corticomedullary) abscesses, which may coexist, are associated with considerable mortality (21 percent to 56 percent) and are often difficult to diagnose. Most cases of renal cortical abscess are due to hematogenous seeding from distant foci of infection (often involving Staphylococcus aureus), while corticomedullary and perinephric abscesses are most often due to complications of urinary tract infections. Newer noninvasive studies such as ultrasonography, computerized tomography, gallium scanning and indium-labeled leukocyte scanning may facilitate determination of the diagnosis. While antibiotic therapy alone may suffice for the treatment of cortical abscesses, surgical drainage is an added requirement for the treatment of perinephric abscess.
PMCID: PMC1273539  PMID: 7039139
15.  Effect of Intrathecal Baclofen Concentration on Spasticity Control: Case Series 
Intrathecal baclofen (ITB) has been shown to be an effective treatment for severe spasticity of spinal or cerebral origin. Although most patients respond well to an ITB trial, there are often difficulties in achieving and/or maintaining such effectiveness with ITB pump treatment. There are few published guidelines for dosing efficacy and no studies looking at the effect of concentration of ITB on spasticity management.
Case series of 3 adults with severe spasticity treated with ITB pump: a 44-year-old man with C7 tetraplegia using a 40-mL Medtronic SynchroMed II pump with 500-μg/mL concentration; a 35-year-old woman with traumatic brain injury with right spastic hemiplegia using a 18-mL Medtronic SynchroMed EL pump with 2,000-μg/mL concentration; and a 43-year-old woman with spastic diplegic cerebral palsy using a 40-mL Medtronic SynchroMed II pump with 2,000-μg/mL concentration.
After reducing ITB concentrations in the pump, either as part of a standard protocol for dye study to assess the integrity of pump and catheter system or secondary to plateau in therapeutic efficacy, patients experienced temporary, significant reduction in spasticity based on range of motion, Modified Ashworth scores, and verbal feedback.
Decreasing the concentration of ITB seems to affect spasticity control. Further research in this area is needed for those patients with refractory spasticity to optimize efficacy of ITB therapy.
PMCID: PMC2582431  PMID: 18959357
Spasticity; Baclofen; Intrathecal; Tetraplegia; Hemiplegia; Cerebral palsy; Traumatic brain injury
16.  Interventional management for complications following caesarean section 
The British Journal of Radiology  2011;84(999):204-209.
This study aimed to evaluate the efficacy and safety of interventional management for various intractable complications following caesarean section.
Between August 2005 and September 2009, 18 consecutive women were referred to interventional radiology for treatment of complications developing after caesarean section. Complications included vaginal bleeding (n = 14), haemoperitoneum with abdominal wall haematoma (n = 2), caesarean scar pregnancy (CSP) (n = 1) and post-caesarean fluid collection (n = 1).
17 women underwent transcatheter arterial embolisation (TAE) with a variety of embolic materials, and two women underwent percutaneous drainage (PCD) for fluid collection and haemoperitoneum. 5 of the 14 women with vaginal bleeding had extravasation of contrast media on angiography; the other 9 had no visible bleeding foci. The two women with haemoperitoneum with abdominal wall haematoma had injury to the inferior epigastric artery from angiography. TAE and PCD were successfully performed in both women. The CSP was successfully managed and the serum β-human chorionic gonadotropin (β-hCG) level finally normalised. Hysterectomy or dilatation and curretage was required in women with placenta accrete and undetectable bleeding foci.
Interventional management including TAE and PCD is effective and safe in controlling complications following caesarean section. Use of these procedures can help avoid high-risk surgery, but subsequent procedures including hysterectomy may be required in cases of placental abnormalities and undetectable bleeding foci.
PMCID: PMC3473877  PMID: 20959367
17.  Status dystonicus resembling the intrathecal baclofen withdrawal syndrome: a case report and review of the literature 
Status dystonicus is a rare but life-threatening disorder characterized by increasingly frequent and severe episodes of generalized dystonia that may occur in patients with primary or secondary dystonia. Painful and repetitive spasms interfere with respiration and may cause metabolic disturbances such as hyperpyrexia, dehydration, respiratory insufficiency, and acute renal failure secondary to rhabdomyolysis. Intrathecally administered baclofen, delivered by an implantable pump system, is widely used for the treatment of refractory spasticity. Abrupt cessation of intrathecal baclofen infusion has been associated with a severe withdrawal syndrome comprised of dystonia, autonomic dysfunction, hyperthermia, end-organ failure and sometimes death. The aetiology of this syndrome is not well understood. Status dystonicus describes the episodes of acute and life-threatening generalized dystonia, which occasionally manifest themselves in patients with dystonic syndromes.
Case presentation
We present the case of a nine-year-old Caucasian boy who experienced a severe episode of status dystonicus with no known cause and clinical features resembling those described in intrathecal baclofen withdrawal. Our patient subsequently underwent the placement of an intrathecal baclofen pump without incident.
The similarity between the clinical features of the case we present and those reported in connection to abrupt withdrawal of intrathecal baclofen is emphasized. Several drugs, although not intrathecal baclofen withdrawal, have previously been associated with status dystonicus. The similarity between the life-threatening dystonic episode experienced by our patient, and those reported in intrathecal baclofen withdrawal, highlights the possibility that, rather than representing a true physiological withdrawal syndrome, abrupt withdrawal of intrathecal baclofen may simply precipitate an episode of status dystonicus in susceptible individuals. The clinical similarities between the intrathecal baclofen withdrawal syndrome and status dystonicus have not previously been highlighted.
PMCID: PMC2939556  PMID: 20807402
18.  Perinephric Capsular Haematoma Associated with Complicated Pyelonephritis in a Patient with HIV 
A 53 year-old-male patient presented with 24 hours of left flank pain. He was an undiagnosed HIV positive individual with no history of trauma. He was anaemic and in acute renal failure with a serum creatinine of 4.14 mg/dL. A CT scan demonstrated a left perinephric capsular haematoma with retroperitoneal stranding. Due to haemodynamic instability, the patient was taken to the operating room and a nephrectomy was performed. Post-operatively, the patient required temporary haemodialysis. Pathologic examination of the specimen demonstrated active infection with a haematoma surrounding a fistulous tract communicating with the capsular surface. Infection is a rare cause of non-traumatic capsular hematomas of the kidney.
PMCID: PMC3649161
19.  Effects of Intrathecal Baclofen on Perceived Sexual Functioning in Men With Spinal Cord Injury 
Reports in the literature suggest that administration of intrathecal baclofen to control spasticity may have deleterious effects on erectile function in men with spinal cord injury (SCI). A prospective study was conducted to document any changes in perceived sexual function after implant of a baclofen pump.
Seven adult men with SCI (ASIA A or B) who received intrathecal baclofen through an implantable pump for treatment of severe spasticity were followed for an average of 670 days (22.4 months) after implant. Perceived sexual function was assessed using the Brief Sexual Function Inventory. Severity of spasticity and overall health-related quality of life were also assessed.
Participants reported improvements in spasticity severity and overall health-related quality of life. Two of 7 participants reported some negative changes in perceived sexual function after baclofen pump implant, noted in the areas of reduced sex drive and problems with erections (frequency, rigidity, difficulty in achieving). However, most participants reported minimal effects on sexual function, and 2 participants reported marked improvement in perceived sexual function from pre- to post-implant. Analysis of changes in perceived sexual function over time suggest that problems may be associated with an increase in baclofen dose and may be reversible with a reduction in dose.
Intrathecal baclofen may impact perceived sexual function particularly at higher doses. However, the effects seem to be reversible with withdrawal or reduction of baclofen administration.
PMCID: PMC2435042  PMID: 18533419
Spinal cord injuries; Baclofen; Spasticity; Sildenafil citrate; Sexual function; Erectile dysfunction
20.  A Bleeding Kiss: intramural haematoma secondary to balloon angioplasty 
Intramural coronary haematoma following percutaneous coronary intervention in the absence of coronary dissection is a rare phenomenon.
Case presentation
A 69 year old lady with previous prosthetic aortic valve replacement underwent percutaneous coronary intervention (PCI) from the left mainstem to the left anterior descending artery (LAD) and kissing balloon inflations to the LAD and circumflex (Cx) arteries. Although intravascular ultrasound examination (IVUS) of both the LAD and Cx showed both vessels to be widely patent at the end of the procedure, she developed ischaemic chest pain six hours later. Repeat coronary angiography revealed a significant stenosis in the proximal Cx vessel, which was confirmed on IVUS to be intramural haematoma.
In patients taking warfarin in addition to standard antiplatelet therapy, kissing balloon inflations should be carried out with caution.
PMCID: PMC1891271  PMID: 17550602
21.  Empyema and Respiratory Failure Secondary to Nephropleural Fistula Caused by Chronic Urinary Tract Infection: A Case Report 
Case Reports in Pulmonology  2012;2012:595402.
We report a case of nephropleural fistula causing empyema and respiratory failure in a 68-year-old gentleman with a long history of urological problems including recurrent nephrolithiasis and urinary tract infections. He was admitted with sepsis, a productive cough, pyuria, and reduced breath sounds over the left hemithorax. Radiological imaging revealed a fistulous connection between a left-sided perinephric abscess and the pleural space. He was commenced on broad spectrum intravenous antibiotics but developed progressive respiratory failure requiring intensive care admission. Urinary and pleural aspirates cultured facultative anaerobic pathogens with identical resistance patterns. Drainage of thoracic and perinephric collections was carried out, allowing him to be extubated after 24 hours and discharged home after 18 days on an extended course of oral antibiotics. Left nephrectomy is now planned after a period of convalescence. Empyema developing in patients with known urolithiasis should alert the treating physician to the possibility that a pathological communication has formed especially if typical urinary tract pathogens are cultured from respiratory sampling.
PMCID: PMC3504369  PMID: 23198240
22.  An unusual complication of silver nitrate therapy for chyluria 
Chyluria is a common disorder in the tropics. In our country it is most commonly managed by instillation of silver nitrate. We report a patient who developed severe perinephric hematoma due to pseudoaneurysm of renal artery following silver nitrate instillation. He was managed by angioembolisation followed by drainage of infected perinephric hematoma. We discuss various modalities of treatment of chyluria including complications of silver nitrate therapy.
PMCID: PMC2721536  PMID: 19675804
Chyluria; pseudoaneurysm; silver nitrate
23.  Could Spontaneous Retroperitoneal Haematoma Present with Scrotal Mass? 
The Libyan Journal of Medicine  2009;4(3):117-119.
Retroperitoneal haematoma could be caused by different factors. It is increasing due to an increase in the use of antithrombotic and anticoagulant therapy. Diagnosis of retroperitoneal haematoma forms a big challenge in daily clinical practice. Patients with retroperitoneal haematoma could present with leg paresis, abdominal pain, shock or abdominal compartment syndrome. Retroperitoneal haematoma could be treated conservatively but surgical interference or embolization of the bleeding vessels is always an option.
To present a case with spontaneous retroperitoneal haematoma presenting with scrotal haematoma together with a mini- review of retroperitoneal haematoma.
Retroperitoneal haematoma may present with a scrotal swelling and could be treated conservatively depending on the presentation and severity of the bleeding.
PMCID: PMC3066735  PMID: 21483527
Retroperitoneal haematoma; Scrotal swelling; Bleeding; Anticoagulant therapy; Antithrombotic therapy
24.  Subcapsular hepatic haematoma after endoscopic retrograde cholangiopancrea-tography: An unusual case 
Subcapsular hepatic haematoma is a rare complication of endoscopic retrograde cholangiopancrea-tography (ERCP), and there are few reports about this unusual complication worldwide. The primary symptom of most cases reported in the literature is abdominal pain. We report an unusual case with the primary symptom of fever. A 56-year-old man who had a six-month history of recurrent episodes of upper abdominal pain was diagnosed with a common bile duct stone by magnetic resonance cholangiopancrea-tography. Endoscopic biliary sphincterotomy was performed, and stones from the common bile duct were successfully extracted with a basket. The patient had a persistent fever after ERCP, and treatment with intravenous antibiotics was unsuccessful. Computed tomography showed a 13 cm × 6 cm subcapsular hepatic haematoma filled with air and liquid on the surface of the right hepatic lobe. The patient was successfully treated with peritoneal drainage under B-ultra guidance. Subcapsular liver haematoma should be considered when hard-to- explain symptoms persist in the early period after ERCP. Percutaneous drainage is an effective treatment.
PMCID: PMC3602514  PMID: 23538782
Endoscopic retrograde cholangiopancrea-tography; Hepatic; Hematoma; Complication; Treatment
25.  Abdominal wall haematoma in the obese: a dangerous phenomenon 
Journal of Surgical Case Reports  2013;2013(7):rjt060.
We report the case of a 59-year-old obese female who developed an abdominal wall haematoma during administration of prophylactic clexane. Compared with the non-obese, the subcutaneous tissue of the obese is considered dysfunctional and has a different vascular structure and extra-cellular matrix composition. While the development of an abdominal wall haematoma is relatively uncommon, when they occur they can have fatal consequences. The altered subcutaneous tissue environment in the obese attenuates the normal external compression of an abdominal wall haematoma and as a result the obese are at greater risk of haemorrhage.
PMCID: PMC3813510

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