We report a case of a primary parahiatal hernia that was repaired laparoscopically with a composite mesh. A 51-year-old woman presented with vomiting and epigastric pain. CT scan showed a giant paraesophageal hernia with intrathoracic gastric volvulus. Intraoperatively, a diaphragmatic muscular defect was found lateral to an attenuated left crus of the diaphragm, distinct from the normal esophageal hiatus. The defect ring was fibrotic, making a tension-free primary repair difficult. A laparoscopic mesh repair was performed with a composite mesh, which was covered with the hernia sac to prevent potential erosion into the esophagus or stomach. Recovery was uneventful and the patient was discharged on the 5 days postoperatively. She remained asymptomatic at subsequent follow-up. Laparoscopic repair of parahiatal hernia can be safely performed. In circumstances where a large or fibrotic defect prevents a tension-free primary repair, the use of a composite mesh can provide effective repair of the hernia.

Introduction True non-traumatic radial artery aneurysms (RAAs) are extremely rare, and few cases have been described. The majority of RAAs are post-traumatic or iatrogenic pseudo-aneurysms following arterial cannulation. However, RAAs due to other causes have also been described. Here a rare case of true idiopathic distal RAA, which was managed by surgical resection and repair with interposition vein graft, is described. Report A 62 year old female with a known medical history of hypertension and hyperlipidaemia presented with left wrist swelling of one year duration, associated with a pulsatile lump that was increasing in size. Duplex ultrasound and computed tomography angiography revealed a distal RAA. She underwent open surgical resection and repair with interposition vein graft using the distal left cephalic vein. Histopathology of the specimen revealed an aneurysm with atherosclerosis. She recovered well post-operatively with no complications. Discussion True idiopathic RAAs are rare. Surgical treatment is almost always recommended in view of the risk of complications. A case of true idiopathic distal RAA is presented here, which was managed successfully by surgical resection and repair with interposition vein graft.

Dear Editor,Brain tumours in pregnancy are rare with an incidence of 15 per 100,000 and previous reports have shown variable outcomes. We present a case of glioblastoma multiforme (GBM) in pregnancy in which the patient underwent emergency craniotomy and adjuvant radiotherapy before delivering a healthy baby with good outcome.

Singapore Med J 2013; 54(1) : 36 O r i g i n a l A r tic le INTRODUCTIONWith the increasing proportion of elderly patients in Singapore, the incidence of severe aortic valve stenosis (AS) (degenerative) is likely to increase. However, there is currently little published data on the epidemiology of AS in the country. We aimed to describe the aetiology and clinical presentation of AS in Singapore, as well as determine patients' attitudes toward it. This study is important for a few reasons. Firstly, many patients with severe AS, especially the elderly, would have associated comorbidities.(1) Although studies have demonstrated benefits from surgical aortic valve replacement, (2)(3)(4)(5)(6) such comorbidities are likely to have an impact on associated risks, complications and the length of hospital stay in this cohort of patients. For this reason, better planning and provision of resources would be possible once the extent of such comorbidities is established.Secondly, patients who are deemed inoperable can now benefit from transcatheter valve therapies. (7,8) The currently available trancatheter heart valves are suitable for aortic annuli of between 18-27 mm. The logistic EuroSCORE, (14,15) which assesses the risk of surgery at the point of diagnosis, was also calculated. Correspondence: Dr Edgar Tay, Consultant Cardiologist, National University Heart Centre, 1E Kent Ridge Road, NUHS Tower Block, Level 9, Singapore 119228.Edgar_Tay@nuhs.edu.sg INTRODUCTIONThe treatment of aortic valve stenosis (AS) is seeing renewed interest mainly due to the availability of transcatheter therapies. However, the number of epidemiological studies of this disease in Singapore is limited. We aimed to describe the aetiology and clinical presentation of AS in Singapore, as well as patients' attitudes toward it. Our findings may facilitate the future planning and utilisation of resources to better manage these patients.METHODS 249 consecutive patients who underwent transthoracic echocardiography (from April 1999 to April 2008 and diagnosed with severe AS were assessed. Demographic and clinical data were collected, and patients' decisions on surgery were determined. RESUlTSThe mean patient age was 71 (range 23-98) years. 50.2% of patients were male. The commonest presenting symptom was dyspnoea, and 40 (16.0%) patients had coexistent atrial fibrillation. The aetiology of AS was degenerative in 216 (86.7%), rheumatic in 11 (4.4%) and related to a bicuspid valve in 22 (8.9%) patients. The average peak velocity across the aortic valve was 4.2 ± 0.8 m/s and the mean aortic valve area was 0.76 ± 0.13 cm 2 . The overall mean logistic EuroSCORE was 10.7 ± 12.3. 105 (42.2%) patients who were offered surgery refused. 87 (35%) deaths were seen during the follow-up period (mean duration 14.5 months), which also saw 68 (27%) patients undergo surgery and 86 (34%) patients hospitalised for heart failure.CONClUSION Degenerative AS was the commonest aetiology in this contemporary cohort of patients. Despite the known benefits of surgery, the refusal rat...