Demands for medical imaging and workforce Size: A nationwide population-based Study, 2000-2020

PURPOSE

The aim of this study was to investigate associations between workforce and workload among radiologists in Taiwan.

MATERIALS AND METHODS

Data for the period 2000-2020 describing the demand for imaging services and radiologists have been obtained from databases and statistical reports of the Ministry of Health and Welfare. The future demand for radiologists was based on Taiwanese people aged 40 and over.

RESULTS

The workforce of Taiwan's radiologists has increased by 6 % annually over the past 20 years (from 450 to 993), performing 2125, 3202 and 3620 monthly examinations (mainly conventional radiography and CT) in medical centers, regional hospitals and district hospitals. Between 2000 and 2020, the use of CT and MRI increased by more than 3.5 times. Demand for interventional radiology also increased by 1.77 times, 2.25 times, and 5 times, respectively. To maintain this volume of services in 2040, at least 1168 radiologists are needed, about 1.18 times more in 2020.

CONCLUSION

Taiwan has 2.4 to 2.9 times fewer radiologists than the United States and 3 times fewer than Europe, while the annual workload is approximately 2 to 3.4 times greater than that of the United States and 1.4 to 2.5 times greater than that of the United Kingdom. This report may serve as a reference for policy makers who address the challenges of the growing workload among radiologists in countries of similar situations.

Sclerotherapy with intralesional bleomycin injection under guidance of multi-slice CT for retrobulbar orbital low-flow vascular lesions-single-center experience

OBJECTIVE

This study investigated the safety and efficacy of sclerotherapy with intralesional bleomycin injection (IBI) for retrobulbar orbital low-flow vascular lesions under multi-slice computed tomography (CT) guidance.

METHODS

Between January 2010 and September 2021, consecutive patients with retrobulbar orbital low-flow vascular lesions who underwent CT-guided IBI at a tertiary centre in Taiwan were enrolled. Their medical records and imaging data were retrospectively collected.

RESULTS

This study enrolled 13 patients (7 male and 6 female patients; age range: 1-57 years; mean age: 25.9 years) with lymphatic malformation (LM, n = 4), venolymphatic malformation (n = 1), and venous malformation (VM, n = 8). The overall radiological response rate was 76.9% (10 of 13); the radiological response rate was 75.0% in the VM group (6 of 8) and 75.0% in the LM group (3 of 4). Moreover, 3 patients (23.1%) had minor complications and 1 (7.7%) had a major complication. The mean clinical and radiological follow-up was 8.3 months and no recurrence or progression was reported.

CONCLUSION

CT-guided IBI is an effective and relatively safe minimally invasive treatment for retrobulbar orbital low-flow vascular lesions, with an overall radiological response rate of 76.9% in a mean of 1.5 sessions and a low complication rate.

ADVANCES IN KNOWLEDGE

CT-guided sclerotherapy with IBI is a relatively safe, effective, and feasible alternative treatment option for retrobulbar orbital low-flow vascular lesions.

Transperineal Targeted Microwave Ablation (TMA) of localized prostate cancer guided by MRI-Ultrasound fusion and organ-based tracking: a pilot study

BACKGROUND

To investigate the efficacy of transperineal targeted microwave ablation (TMA) in treating localized prostate cancer (PCa).

METHODS

This is a single-centre prospective phase 2 trial recruiting men with low to intermediate-risk localized PCa to undergo transperineal TMA. TMA was performed with MRI-Ultrasound fusion guidance and organ-based tracking. A per-protocol 6-month MRI and biopsy were performed for all patients. The primary outcome was any cancer detected on biopsy of each ablated area. Secondary outcomes included per-patient analysis of positive biopsy, complications, urinary symptom score, erectile function and quality of life (QOL) scores.

RESULTS

In the first 15 men, 23 areas were being treated. The median age was 70 years, number of TMA ablations were 5 (range 2-8), and the total ablation time and operating time was 22 (IQR 14-28) and 75 (IQR 65-85) minutes, respectively. PSA level dropped from a median of 7.7 to 2.4 ng/mL. For the primary outcome, 91.3% (21/23) ablated area had no cancer in 6-month biopsy. In per-patient analysis, 33.3% (5/15) had in or out-of-field positive biopsy at 6 months. Among these five cases, four of them were amenable to active surveillance and 1 (6.7%) case with out-of-field ISUP grade group 2 cancer received radiotherapy. The urinary symptoms, uroflowmetry, erectile function, and QOL scores had no significant difference at 6 months. One patient (out of five patients with normal erection) in the cohort complained of significant worsening of erectile function after TMA. Grade 1 complications including hematuria (33.3%), dysuria (6.7%), and perineal discomfort (13.4%) were observed.

CONCLUSIONS

In this first pilot study, transperineal TMA guided by MRI-Ultrasound fusion guidance and organ-based tracking was shown to be effective, safe, and easily applicable in men with localized PCa.

Comparing transvenous coiling and transarterial embolization with Onyx/NBCA for cavernous sinus dural arteriovenous fistulas: a retrospective study in a single center

BACKGROUND

Endovascular management is the gold standard for cavernous sinus dural arteriovenous fistulas (CS-dAVFs) in patients with signs of ophthalmoplegia, visual defects, or intolerable clinical symptoms. Although the efficacy of embolization has been confirmed, complications during post-endovascular management have not been compared in a more extensive CS-dAVFs case series. Therefore, we compared the effectiveness and peri-procedural complications of transvenous coiling with those of transarterial embolization (TAE) using liquid embolic agents.

MATERIAL AND METHODS

We reviewed 71 patients with CS-dAVFs in one medical center from 2005/7 to 2016/7. We performed seventy-seven procedures on 71 patients, including six recurrent cases. We compared the efficacy and peri-procedural complications of transvenous coiling and TAE.

RESULTS

The complete occlusion rate for transvenous coiling was 79.2%, and that for TAE was 75.0%. Findings revealed (1) similar ophthalmoplegia complication rates (p = 0.744); (2) more frequent and permanent CN5 or CN7 neuropathy with liquid embolic agent use (p = 0.031 and 0.028, respectively); and (3) a higher risk of infarction or ICH (p =0.002 and 0.028, respectively) in response to aggressive TAE.

CONCLUSION

Transvenous cavernous sinus coiling resulted in a similar occlusion rate and lower complication risk than transarterial Onyx/n-butyl cyanoacrylate (NBCA). We can access via an occluded inferior petrosal sinus (even contralateral), and direct transorbital puncture was a safe alternative. TAE with Onyx/NBCA was helpful in cases of oligo-feeders, but multidisciplinary treatment and multi-session TAE were usually needed for patients with multiple feeders and complex fistulas.

Long-term outcomes of coils embolization for superior hypophyseal artery aneurysms

Objective

Superior hypophyseal artery (SHA) aneurysms are intradural, and their rupture can result in subarachnoid hemorrhage. Considering the related surgical difficulty and anatomical restrictions, endovascular treatment (EVT) is considered the most favorable modality for SHA aneurysms; however, the long-term outcomes of EVT have rarely been reported. The study assessed the incidence of and risk factors for recurrence of SHA aneurysms after EVT as well as the correlation factors for SHA aneurysm rupture.

Methods

We included 112 patients with SHA aneurysms treated with EVT at our facility between 2009 and 2020. Here, EVT included non-stent-assisted (simple or balloon-assisted) or stent-assisted coiling. Flow diverter was not included because it was barely used due to its high cost under our national insurance's limitation, and a high proportion of ruptured aneurysms in our series. Univariate and multivariate logistic regression was performed to evaluate the correlation factors for SHA aneurysm rupture, along with the incidence of and risk factors for post-EVT SHA aneurysm recurrence and re-treatment.

Results

In our patients, the mean angiographic follow-up period was 3.12 years. The presence of type IA or IB cavernous internal carotid artery (cICA) was strongly correlated with SHA aneurysm rupture. Recurrence occurred in 17 (13.4%) patients, of which only 1 (1.4%) patient had received stent-assisted coiling. All cases of recurrence were observed within 2 years after EVT. The multivariate logistic regression results showed that ruptured aneurysm and non-stent-assisted coiling were independent risk factors for aneurysm recurrence. Of the 17 cases of aneurysm recurrence, 9 (52.9%) received re-treatment. Moreover, aneurysm rupture was the only factor significantly correlated with re-treatment in multivariate logistic regression. No re-recurrence was observed when a recurrent aneurysm was treated with stent-assisted coiling.

Conclusion

Type I cICA was common factor for aneurysm rupture. Although flow-diverter treatment serves as another suitable technique that was not compared with, coils embolization was effective treatment modality for SHA aneurysms, leading to low recurrence and complication rates, especially with stent use. All cases of recurrence occurred within 2 years after EVT; they were strongly associated with prior aneurysm rupture. Further stent-assisted coiling was noticed to prevent re-recurrence.

Comparison of neostigmine and sugammadex for hemodynamic parameters in neurointerventional anesthesia

Introduction

Hemodynamic stability is important during neurointerventional procedures. However, ICP or blood pressure may increase due to endotracheal extubation. The aim of this study was to compare the hemodynamic effects of sugammadex and neostigmine with atropine in neurointerventional procedures during emergence from anesthesia.

Methods

Patients undergoing neurointerventional procedures were allocated to the sugammadex group (Group S) and the neostigmine group (Group N). Group S was administered IV 2 mg/kg sugammadex when a train-of-four (TOF) count of 2 was present, and Group N was administered neostigmine 50 mcg/kg with atropine 0.2 mg/kg at a TOF count of 2. We recorded heart rate, systolic blood pressure, diastolic blood pressure, mean blood pressure (MAP), and peripheral arterial oxygen saturation during administration of the reverse agent and at 2, 5, 10, 15, 30, 120 min, and 24 h thereafter. The primary outcome was blood pressure and heart rate change after the reversal agent was given. The secondary outcomes were systolic blood pressure variability standard deviation (a measure of the amount of variation or dispersion of a set of values), systolic blood pressure variability-successive variation (square root of the average squared difference between successive blood pressure measurements), nicardipine use, time-to-TOF ratio ≥0.9 after the administration of reversal agent, and time from the administration of the reversal agent to tracheal extubation.

Results

A total of 31 patients were randomized to sugammadex, and 30 patients were randomized to neostigmine. Except for anesthesia time, there were no significant differences in any of the clinical characteristics between the two groups. The results demonstrated that the increase in MAP from period A to B was significantly greater in Group N than in Group S (regression coefficient = -10, 95% confidence interval = -17.3 to -2.7, P = 0.007). The MAP level was significantly increased from period A to B in the neostigmine group (95.1 vs. 102.4 mm Hg, P = 0.015), but it was not altered in Group S. In contrast, the change in HR from periods A to B was not significantly different between groups.

Conclusion

We suggest that sugammadex is a better option than neostigmine in interventional neuroradiological procedures due to the shorter extubation time and more stable hemodynamic change during emergence.

Concomitant spinal dural arteriovenous fistula and nodular fasciitis in an adolescent: case report

Background

Spinal dural arteriovenous fistula (SDAVF) usually occurs during the 4^th to 6^th decades of life, and adolescent SDAVF is rarely reported. SDAVF arising around a tumor is also rare, and reported tumors are mostly schwannoma and lipoma.

Case presentation

We reported a 16-year-old male presented with progressive weakness and numbness of lower limbs for 3 months. A SDAVF was found, which was fed by right radicular arteries from segmental artery at L2 level and drained retrogradely into perimedullary veins. A concomitant spinal extradural nodular fasciitis at right L1/L2 intervertebral foramen was also noted. The SDAVF was completely obliterated by endovascular treatment and the tumor was debulked. The patient recovered well after the procedures.

Conclusions

Our case report suggests SDAVF can occur in adolescent. The concomitant presence with a nodular fasciitis indicates that although it usually arises in subcutaneous tissue but can rarely form on the dura of spine.

Endovascular Treatment of Medial Tentorial Dural Arteriovenous Fistula Through the Dural Branch of the Pial Artery

Background: Tentorial dural arteriovenous fistula is a rare subtype of intracranial dural arteriovenous fistula (DAVF) with a deteriorating natural course, which may be attributed to its pial angioarchitecture. TDAVF often harbors feeders arising from pial arteries (FPAs). Reports have revealed that, if these feeders are not obliterated early, the restricted venous outflow during the embolization process may cause upstream congestion in the fragile pial network, which increases the risk of hemorrhagic complications. Because most reported cases of TDAVF were embolized through feeders from non-pial arteries (FNPAs), little is known of the feasibility of direct embolization through FPAs.

Methods: We present three patients with medial TDAVFs that were embolized through the dural branches of the posterior cerebral and superior cerebellar arteries. Findings from brain magnetic resonance imaging, computed tomography, angiography, and clinical outcomes are described. Furthermore, we performed a review of the literature on TDAVFs with FPAs.

Results: The fistulas were completely obliterated in two patients; both recovered well with no procedure-related complications. The fistula was nearly obliterated in one patient, who developed left superior cerebellum and midbrain infarct due to the reflux of the embolizer into the left superior cerebellar artery. Including our cases, eight cases of TDAVFs with direct embolization through the FPAs have been reported, and ischemic complications occurred in three (37.5%).

Conclusions: Advancing microcatheter tips as close to the fistula point as possible and remaining highly aware of potential embolizer flow back into the pial artery are key factors in achieving successful embolization. Balloon-assisted embolization may be an option for treating TDAVFs with FPAs in the future.

Management of intracranial vertebral artery stenosis with ipsilateral vertebral artery hypoplasia and contralateral vertebral artery occlusion via type 2 proatlantal intersegmental artery

BACKGROUND

Proatlantal intersegmental artery (PIA) is a rare primitive carotid-basilar anastomosis. PIA may accompany with ipsilateral or bilateral vertebral arteries (VAs) agenesis. Here, we presented the case with intracranial VA stenosis supplying via PIA and demonstrated how we evaluated and managed.

METHODS

Dual antiplatelet therapy and adequate hydration were given for three weeks for intracranial atherosclerotic disease (ICAD). We arranged magnetic resonance (MR) vessel wall imaging to survey both intracranial VAs. Intracranial right VA stenosis supplying via PIA with ipsilateral VA hypoplasia and contralateral intracranial VA occlusion caused multiple posterior circulation infarcts. We performed angioplasty and intracranial stenting for ICAD at the right VA V4 segment via PIA.

RESULTS

National Institute of Health Stroke Scale (NIHSS) and modified Rankin scale (mRS) got improved at discharge and ten months.

CONCLUSIONS

This case is the first report for ICAD management via PIA. A persistent type 2 PIA is essential for supplying posterior circulation.

Effect of SARS and COVID-19 outbreaks on urology practice and training

INTRODUCTION

The objective was to investigate the changes in urology practice during coronavirus disease 2019 (COVID-19) pandemic with a perspective from our experience with severe acute respiratory syndrome (SARS) in 2003.

METHODS

Institutional data from all urology centres in the Hong Kong public sector during the COVID-19 pandemic (1 Feb 2020-31 Mar 2020) and a non-COVID-19 control period (1 Feb 2019-31 Mar 2019) were acquired. An online anonymous questionnaire was used to gauge the impact of COVID-19 on resident training. The clinical output of tertiary centres was compared with data from the SARS period.

RESULTS

The numbers of operating sessions, clinic attendance, cystoscopy sessions, prostate biopsy, and shockwave lithotripsy sessions were reduced by 40.5%, 28.5%, 49.6%, 44.8%, and 38.5%, respectively, across all the centres reviewed. The mean numbers of operating sessions before and during the COVID-19 pandemic were 85.1±30.3 and 50.6±25.7, respectively (P=0.005). All centres gave priority to cancer-related surgeries. Benign prostatic hyperplasia-related surgery (39.1%) and ureteric stone surgery (25.5%) were the most commonly delayed surgeries. The degree of reduction in urology services was less than that during SARS (47.2%, 55.3%, and 70.5% for operating sessions, cystoscopy, and biopsy, respectively). The mean numbers of operations performed by residents before and during the COVID-19 pandemic were 75.4±48.0 and 34.9±17.2, respectively (P=0.002).

CONCLUSION

A comprehensive review of urology practice during the COVID-19 pandemic revealed changes in every aspect of practice.

Left ventricular systolic dysfunction is associated with poor functional outcomes after endovascular thrombectomy

BACKGROUND

Endovascular thrombectomy (ET) has transformed acute ischemic stroke (AIS) therapy in patients with large vessel occlusion (LVO). Left ventricular systolic dysfunction (LVSD) decreases global cerebral blood flow and predisposes to hypoperfusion. We evaluated the relationship between LVSD, as measured by LV ejection fraction (LVEF), and clinical outcomes in patients with anterior cerebral circulation LVO who underwent ET.

METHODS

This multicenter retrospective cohort study examined anterior circulation LVO AIS patients from six international stroke centers. LVSD was measured by assessment of the echocardiographic LVEF using Simpson's biplane method of discs according to international guidelines. LVSD was defined as LVEF <50%. The primary outcome was defined as a good functional outcome using a modified Rankin Scale (mRS) of 0-2 at 3 months.

RESULTS

We included 440 AIS patients with LVO who underwent ET. On multivariate analyses, pre-existing diabetes mellitus (OR 2.05, 95% CI 1.24 to 3.39;p=0.005), unsuccessful reperfusion (Treatment in Cerebral Infarction (TICI) grade 0-2a) status (OR 4.21, 95% CI 2.04 to 8.66; p<0.001) and LVSD (OR 2.08, 95% CI 1.18 to 3.68; p=0.011) were independent predictors of poor functional outcomes at 3 months. On ordinal (shift) analyses, LVSD was associated with an unfavorable shift in the mRS outcomes (OR 2.32, 95% CI 1.52 to 3.53; p<0.001) after adjusting for age and ischemic heart disease.

CONCLUSION

Anterior circulation LVO AIS patients with LVSD have poorer outcomes after ET, suggesting the need to consider cardiac factors for ET, the degree of monitoring and prognostication post-procedure.

Cerebral Air Embolism and Vasospasm after Carotid Revascularization: A Case Report

Cerebral air embolism can be of venous and arterial origin and cause severe medical complication. Vasospasm is a severe complication of carotid artery stenting. We report a 63-year-old male with severe carotid artery stenosis who suddenly died due to acute myocardial infarction during carotid artery stenting. His brain computed tomogram showed a remarkable amount of air in the gyriform spaces, and the cerebral angiogram showed vasospasm in the internal carotid artery resulting from stent manipulation. Presence of gyriform air could be caused by air entering the catheter due to sudden collapse after acute myocardial infarction and severe carotid vasospasm.

Endovascular Treatment of Ruptured Proximal Segment of the Anterior Cerebral Artery Aneurysms: Single-Center Experience and Literature Review

BACKGROUND

Proximal anterior cerebral artery (A1) aneurysms are rare among all intracranial aneurysms and are regarded as difficult to treat endovascularly. Treatment is even more challenging in patients with ruptured aneurysms and acute subarachnoid hemorrhage owing to the small size and proximity to perforators. Though challenging, endovascular treatment can provide favorable outcomes in such patients. We report our case series of endovascular treatment in ruptured proximal A1 aneurysms.

METHODS

Between January 2010 and December 2017, 1200 aneurysms were treated endovascularly at our center. There were 15 patients with 15 ruptured proximal A1 aneurysms who presented with subarachnoid hemorrhage. Five patients underwent simple coiling, 9 underwent balloon-assisted coiling, and 1 underwent catheter protective coiling. Medical records and angiographic results were obtained retrospectively.

RESULTS

All aneurysms were successfully treated with endovascular techniques. Multiplicity rate was 53.3% (n = 8). Initial complete obliteration rate was 93.3% (n = 14), with a 13.3% recurrence rate (n = 2). One patient experienced intraoperative bleeding; this was the only procedure-related complication. Eleven patients (73.3%) had a good clinical outcome. When excluding Hunt and Hess grade 4 patients, the good outcome rate was 81.8%.

CONCLUSIONS

Ruptured proximal A1 aneurysm is a rare condition and is highly associated with multiple aneurysms. Despite being a more difficult and complicated technique, endovascular coiling performed in high-volume, experienced medical centers is an effective modality with excellent clinical outcomes.

Asymmetric Cerebrovascular Collateral Supply Affects Cognition in Patients with Unilateral Carotid Artery Stenosis

BACKGROUND

The time to maximum of the residue function (TMax) has been employed to identify the penumbra in acute ischemic stroke. Cognitive impairment in patients with Carotid Artery Stenosis (CAS) has been attributed to chronic cerebral hypoperfusion. The study aimed to examine whether cognitive impairment can be detected based on a preliminary TMax cutoff in patients with unilateral CAS.

METHODS

Fifty unilateral CAS patients underwent dynamic susceptibility contrast MR perfusion. The preliminary TMax cutoff (3 seconds) was derived on the basis of the upper limit of 95% confidence interval of TMax in the Middle Cerebral Artery (MCA) contralateral to the CAS side. All patients were allocated to the Right-delayed group (n=18), Left-delayed group (n=12), and Nondelayed group (n=20) by the cutoff. Cognitive assessment was also administered on all patients and 22 healthy volunteers.

RESULTS

No significant interhemispheric mean TMax differences of the Non-delayed group were noted (p=0.75), but the mean TMax of ipsilateral MCA was significantly longer than that of the contralateral MCA of the Left- and Right-delayed groups (ps<0.001), respectively. Compared to healthy volunteers, the Right-delayed group performed significantly worse on most of the visuospatial tests (ps<0.04), while the Left-delayed group performed significantly worse on most of the verbal tests (ps<0.05). The performance of the Non-delayed group on all cognitive domains was similar to that of healthy volunteers (ps>0.07).

CONCLUSION

TMax can be used to differentiate the chronic hypoperfusion state in unilateral CAS patients. Prolonged TMax in the MCA of either hemisphere may lead to lateralized impairment in cognition functions in patients with unilateral CAS.

Photo-oxygenation of Phytol and the Structure Revision of Phytene-1,2-diol from Artemisia annua to Phytene-1-ol-2-Hydroperoxidek

Photo-oxygenation of racemic phytol has yielded two secondary allylic hydroperoxides and an endoperoxide hemi-acetal, which are the expected products from the “ene-type” reaction of singlet oxygen with the tri-substituted double bond in phytol. Spectral properties for one of the diastereoisomers of phytene-1-ol-2-hydroperoxide obtained from synthesis are shown to be identical with those of a natural product previously reported from Artemisia annua, which, it is concluded, was wrongly assigned as phytene-1,2-diol.

The correlation of asymmetrical functional connectivity with cognition and reperfusion in carotid stenosis patients

Objective

Neural disruption and cognitive impairment have been reported in patients with carotid stenosis (CS), but carotid artery stenting (CAS) may not contribute to the cognitive recovery. Although functional hyper-connectivity is one of the physiological over-compensation phenomena in neurological diseases, the literature on the cognitive influence of functional hyper-connectivity in CS patients is limited. We aimed to investigate the longitudinal changes of hyper-connectivity after CAS and its association with cognition in CS patients.

Methods

Thirteen patients with unilateral CS and 17 controls without CS were included. Cognitive function was evaluated at baseline, and resting-state functional MRI was performed 1 week before and 1 month and 1 year after CAS. Comparisons of functional connectivity (FC) between CS patients and controls in multiple brain networks were performed.

Results

In patients before CAS, FC in the cerebral hemispheres ipsilateral and contralateral to CS was mainly decreased and increased, respectively, compared with normal controls. Part of the FC alterations gradually recovered to the normal condition after CAS. The stronger FC abnormality (both hypo- and hyper-connectivity compared with normal controls) was associated with poorer cognitive performances, especially in memory and executive functions.

Conclusion

The study demonstrated the lateralization of hyper-connectivity and hypo-connectivity in patients with unilateral CS in contrast to the FC in normal controls. These FC alterations were associated with poor cognitive performances and tended to recover after CAS, implying that hyper-connectivity is served as a compensation for neural challenge.

•

Cerebral hypoconnectivity on functional MRI is lateralized to carotid stenosis side.

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Cerebral hyperconnectivity is in regions contralateral to carotid stenosis side.

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Abnormal connectivity gradually returns back to normal after carotid stenting.

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Hypo- and hyper-connectivity associate with poor cognitive performances.

•

Hyperconnectivity could be served as a compensation for neural challenge.

Magnetic resonance cholangiogram patterns and clinical profiles of ketamine-related cholangiopathy in drug users

BACKGROUND & AIMS

Recreational ketamine use has emerged as an important health and social issue worldwide. Although ketamine is associated with biliary tract damage, the clinical and radiological profiles of ketamine-related cholangiopathy have not been well described.

METHODS

Chinese individuals who had used ketamine recreationally at least twice per month for six months in the previous two years via a territory-wide community network of charitable organizations tackling substance abuse were recruited. Magnetic resonance cholangiography (MRC) was performed, and the findings were interpreted independently by two radiologists, with the findings analysed in association with clinical characteristics.

RESULTS

Among the 343 ketamine users referred, 257 (74.9%) were recruited. The mean age and ketamine exposure duration were 28.7 (±5.8) and 10.5 (±3.7) years, respectively. A total of 159 (61.9%) had biliary tract anomalies on MRC, categorized as diffuse extrahepatic dilatation (n = 73), fusiform extrahepatic dilatation (n = 64), and intrahepatic ductal changes (n = 22) with no extrahepatic involvement. Serum alkaline phosphatase (ALP) level (odds ratio [OR] 1.007; 95% CI 1.002-1.102), lack of concomitant recreational drug use (OR 1.99; 95% CI 1.11-3.58), and prior emergency attendance for urinary symptoms (OR 1.95; 95% CI 1.03-3.70) had high predictive values for biliary anomalies on MRC. Among sole ketamine users, ALP level had an AUC of 0.800 in predicting biliary anomalies, with an optimal level of ≥113 U/L having a positive predictive value of 85.4%. Cholangiographic anomalies were reversible after ketamine abstinence, whereas decompensated cirrhosis and death were possible after prolonged exposure.

CONCLUSIONS

We have identified distinctive MRC patterns in a large cohort of ketamine users. ALP level and lack of concomitant drug use predicted biliary anomalies, which were reversible after abstinence. The study findings may aid public health efforts in combating the growing epidemic of ketamine abuse.

LAY SUMMARY

Recreational inhalation of ketamine is currently an important substance abuse issue worldwide, and can result in anomalies of the biliary system as demonstrated by magnetic resonance imaging. Although prolonged exposure may lead to further clinical deterioration, such biliary system anomalies might be reversible after ketamine abstinence. Clinical trial number: NCT02165488.

Prophylactic Dual Catheter Technique to Prevent Side Branch Snowplowing Complications during Angioplasty and Stenting

Objective

Angioplasty and Stenting of intracranial atherosclerotic lesions have a higher complication rate and a large proportion of this is attributable to side branch arterial occlusion from forceful displacement of the atheroma into the ostia or snowplowing effect. This can result in severe disabilities when it result in small infarcts involving eloquent areas in the posterior circulation or the motor tracts.

Materials and Methods

We present a series of 6 cases utilizing a new dual catheter technique for maintaining the patency of at-risk vessels during angioplasty and stenting. There are several methods previously described to help reduce the incidence of stroke but because they do not have a physical presence in the ostia to protect it, they are unable to guarantee the patency of the vessel.

Results

All 6 patients underwent angioplasty and stenting with the technique. The patients were assessed for complications with post-procedure magnetic resonance imaging and no complications were found.

Conclusion

In this preliminary series, the dual catheter technique appears to safe and effective in preventing occlusion of the adjacent branch arteries. This technique may facilitate the use of the Wingspan stent in the treatment of intracranial atherosclerotic stenotic segments by reducing the risk of peri-procedural stroke.

MRI audit of complications in intracranial stenosis treated with Wingspan device

OBJECTIVES

To evaluate the safety and efficacy of the Wingspan device for the treatment of symptomatic intracranial atherosclerotic stenosis (ICAS).

METHODS

We audited a prospective ongoing database of consecutive patients who received Wingspan stenting between January 2013 and December 2015. All patients underwent MRI to audit any complications during the early follow-up period. We focused on the clinical demographics, lesion characteristics, treatment results, and periprocedural complications. Functional outcomes were measured with the modified Rankin Scale (mRS) at discharge and after 3 months.

RESULTS

Intracranial stenting was performed in 50 patients (100%). Mean stenosis pre-stenting was 76.5±13.1% and post-stenting residual stenosis was 19.8±13.8%. The overall 30-day rate of procedure-related complications was 6.0% (3/50). Two patients (4%) developed in-stent restenosis, one of whom had a dissection at the middle cerebral artery. Interestingly, on the follow-up MRI scan there was a high incidence of asymptomatic diffusion-weighted imaging (DWI) hyperintensities, 46% (23/50) presumed to be due to microembolic causes. At the 90-day, 180-day, and 1-year follow-up, three patients had further strokes resulting in a total complication rate of 12%. 92% had excellent outcomes (mRS 0-1) and only one patient had deterioration of his mRS score.

CONCLUSIONS

ICAS treated by Wingspan stenting using pre-placement balloon angioplasty appears safe and effective with a high technical success rate and favorable outcomes. There is a high incidence of asymptomatic DWI hyperintensites post-procedure, but these do not appear to result in long-term sequelae.

Quantitative flow measurement after placing a flow diverter for a distal internal carotid artery aneurysm

Objectives

To evaluate the differences in arterial flow after flow diverter placement using quantitative flow measurements based on digital subtraction angiography (DSA).

Methods

Between November 2013 and November 2015, all patients who had flow diverters placed for distal internal carotid artery (ICA) aneurysms were reviewed. Patients in whom the stent was placed across the ostia of the ophthalmic artery (OphA) and anterior choroidal artery (AChA) were enrolled. Five regions of interest were selected: the proximal ICA (as a reference), terminal ICA, middle cerebral artery (MCA), anterior cerebral artery (ACA), OphA, and AChA. The values of the peak, time-to-peak (TTP), and area under the curve (AUC) were analyzed using a quantitative DSA technique.

Results

The study enrolled 13 patients. The quantitative flow analysis showed improved flow in the terminal ICA (peak and AUC, p=0.036 and p=0.04, respectively), MCA (AUC, p=0.023), and ACA (AUC, p=0.006), and decreased flow in the OphA (peak and AUC, p=0.013 and p=0.005, respectively) and AChA (peak and subtracted TTP, p=0.023 and p=0.050, respectively) after flow diverter placement. Larger aneurysm volume was significantly correlated with decreased OphA flow after the procedure (peak and AUC, p=0.049 and p=0.037, respectively). Larger aneurysm volume also had a marginal correlation with increased distal ICA flow after the procedure, but this did not reach significance (peak and AUC, p=0.195 and p=0.060, respectively).

Conclusions

Without using extra contrast medium or radiation dosages, color-coded DSA enables quantitative monitoring of the cerebral circulation after flow-diverting treatment.

De novo formation of cerebral cavernous malformation adjacent to existing developmental venous anomaly - an effect of change in venous pressure associated with management of a complex dural arterio-venous fistula

This is a case report of de novo development of two cerebral cavernous malformations adjacent to existing developmental venous anomalies. The development of cavernomas was noted over a follow-up period of 10 years. These developments happened during the course of staged endovascular management of a complex dural arterio-venous fistula along the right sphenoid wing. The patient presented with a proptosis secondary to lympho-haemangiomatous lesion of the fronto-orbital region and a high-flow right sphenoid wing dural arterio-venous fistula. During the initial period of conservative management of the dural arterio-venous fistula, he developed de novo cavernous malformations in the left mesial temporal lobe adjacent to a developmental venous anomaly in the temporal lobe, and along with this there was engorgement of deep veins related to another existing developmental venous anomaly in the brainstem. Later during the course of endovascular treatment of the dural arterio-venous fistula, a large brainstem cavernoma developed adjacent to the brainstem developmental venous anomaly. This case report discusses the cause-effect relationship of venous pressure changes related to management of dural arterio-venous fistula and de novo formation of cerebral cavernous malformations adjacent to existing developmental venous anomalies.

Intravenous Thrombolysis for Acute Ischemic Stroke due to Cervical Internal Carotid Artery Occlusion

BACKGROUND

Internal carotid artery (ICA) occlusions are poorly responsive to intravenous thrombolysis with tissue plasminogen activator (IV-tPA) in acute ischemic stroke (AIS). Most study populations have combined intracranial and extracranial ICA occlusions for analysis; few have studied purely cervical ICA occlusions. We evaluated AIS patients with acute cervical ICA occlusion treated with IV-tPA to identify predictors of outcomes.

METHODS

We studied 550 consecutive patients with AIS who received IV-tPA and identified 100 with pure acute cervical ICA occlusion. We evaluated the associations of vascular risk factors, National Institutes of Health Stroke Scale (NIHSS) score, and leptomeningeal collateral vessel status via 3 different grading systems, with functional recovery at 90 days, mortality, recanalization of the primary occlusion, and symptomatic intracranial hemorrhage (SICH). Modified Rankin Scale score 0-1 was defined as an excellent outcome.

RESULTS

The 100 patients had mean age of 67.8 (range 32-96) and median NIHSS score of 19 (range 4-33). Excellent outcomes were observed in 27% of the patients, SICH in 8%, and mortality in 21%. Up to 54% of the patients achieved recanalization at 24 hours. On ordinal regression, good collaterals showed a significant shift in favorable outcomes by Maas, Tan, or ASPECTS collateral grading systems. On multivariate analysis, good collaterals also showed reduced mortality (OR .721, 95% CI .588-.888, P = .002) and a trend to less SICH (OR .81, 95% CI .65-1.007, P = .058). Interestingly, faster treatment was also associated with favorable functional recovery (OR 1.028 per minute, 95% CI 1.010-1.047, P = .001).

CONCLUSIONS

Improved outcomes are seen in patients with early acute cervical ICA occlusion and better collateral circulation. This could be a valuable biomarker for decision making.

Graph theoretical analysis of functional networks and its relationship to cognitive decline in patients with carotid stenosis

Significant carotid stenosis compromises hemodynamics and impairs cognitive functions. The interplay between these changes and brain connectivity has rarely been investigated. We aimed to discover the changes of functional connectivity and its relation to cognitive decline in carotid stenosis patients. Twenty-seven patients with unilateral carotid stenosis (≥60%) and 20 age- and sex-matched controls underwent neuropsychological tests and resting-state functional magnetic resonance imaging. The patients also received perfusion magnetic resonance imaging. The relationships between cognitive function and functional networks among the patients and controls were evaluated. Graph theory was applied on resting-state functional magnetic resonance imaging network analysis, which revealed that the hemispheres ipsilateral to the stenosis were significantly impaired in "degree" and "global efficiency." The neuropsychological performances were positively correlated with degree, clustering coefficient, local efficiency, and global efficiency, and negatively correlated with characteristic path length, modularity, and small-worldness in the patients, whereas these relationships were not observed in the controls. In this study, we identified the networks that were impaired in the affected hemispheres in patients with carotid stenosis. Specific indices (global efficiency, characteristic path length, and modularity) were highly correlated with neuropsychological performance in our patients. Analysis of brain connectivity may help to elucidate the relationship between hemodynamic impairment and cognitive decline.

Application of Onyx for Renal Arteriovenous Malformation With First Case Report of a Renal Hyperdense Striation Sign: A CARE-Compliant Article

Onyx is an emerging treatment modality for visceral vascular malformations, especially in cases in which delicate nidal penetration of the arteriovenous malformation (AVM) is desired. A computed tomography (CT) image presentation of hyperdense striations along the renal medulla secondary to the tantalum powder has not been previously reported. A 65-year-old woman presented to our institution with intermittent gross hematuria and left flank pain for 10 days. Both CT and conventional angiographies confirmed cirsoid-type renal AVM, which was successfully treated with Onyx. Follow-up CT after treatment revealed presence of hyperdense striations along the renal medulla, which resolved during later image follow-up. Despite its frequent usage in neural intervention, the application of Onyx in visceral AVM is gradually gaining interest, especially in cases in which delicate nidal penetration of the AVM is desired. Renal hyperdense striation sign should be recognized to avoid confusion with embolizer migration, and further studies in patients with renal function impairment may be helpful in understanding its influence of renal function.

Spinal intraosseous epidural arteriovenous fistula with perimedullary drainage obliterated with Onyx embolization: case report

The authors report an extremely rare case of spinal intraosseous epidural arteriovenous fistula (AVF) with perimedullary vein reflux causing symptoms of myelopathy. The intraosseous fistula tracts were completely obliterated with Onyx embolic agent, resulting in a total resolution of symptoms. The unique features of this case include the rare location of the fistula in the vertebral body and the association of the fistula with a compressive fracture. Imaging studies confirmed these hemodynamic findings and provided clarity and direct evidence regarding the association of epidural AVF formation with the vertebral compressive fracture. The authors also propose a possible disease evolution based on the previously adduced reflux-impending mechanism.

Anatomically based approach for endovascular treatment of vertebro-vertebral arteriovenous fistula

Vertebro-vertebral arteriovenous fistula (VV-AVF) is a rare vascular disorder with an abnormal high-flow shunt between the extracranial vertebral artery (VA), its muscular or radicular branches and an adjacent vein. To date, there are no guidelines on the best treatment for VV-AVF. We present our experience of VV-AVF treatment with covered stents in three patients and detachable coils in two patients. One patient with fistula at the V3 segment had rapid fistula recurrence one week after covered stent treatment. The possible causes of failed treatment in this patient are discussed. The currently available treatment modalities for VV-AVF are also summarized after a literature review. At the end of this article, we propose a new concept of anatomically based approach for endovascular treatment of VV-AVF. Fistula in the V1-2 segments of vertebral artery could be treated safely and effectively by covered stent with the benefit of preserving VA patency. Embolization with variable embolizers should be considered first for fistula in the V3 segment because of the tortuous course and flexibility of the VA in this segment.

Selective ophthalmic arterial injection of melphalan for intraocular retinoblastoma: a 4-year review

PURPOSE

To describe tumor response and complications after selective ophthalmic arterial injection (SOAI) of melphalan for treatment of intraocular retinoblastoma.

METHODS

A retrospective review of 17 eyes (12 patients) treated with SOAI of melphalan from January 2010 through December 2013 at Chang Gung Memorial Hospital.

RESULTS

SOAI was successfully performed in 49 of 54 attempts. Six eyes underwent SOAI as the primary treatment and 11 eyes had previously been treated with other treatment modalities. Subsequent to SOAI, tumor regression was observed in 12 of 17 eyes, and vitreous seeding with complete or partial regression in ten of 15 eyes. Globe salvage was achieved in ten of 17 eyes, with three of four in group B and group C eyes, and seven of 13 in group D and group E eyes. Pancytopenia accompanied by neutropenic fever was observed in one case. Twelve eyes had local side effects, including lid edema (two eyes), third cranial nerve palsy (two eyes), sixth cranial nerve palsy (one eye), chorioretinal atrophy (six eyes), retinal arterial occlusion (three eyes), retinal detachment (one eye), and vitreous hemorrhage (seven eyes). Three cases with high-risk features, according to the histopathologic examination, had metastatic disease, and two of them died.

CONCLUSIONS

SOAI of melphalan is an effective treatment for intraocular retinoblastoma, achieving high globe salvage in cases of advanced disease, but can be associated with significant ocular complications. Repetitive SOAI with delayed enucleation could increase the risk of metastasis when used in high-risk cases. Therefore, clinicians should consider the benefits and potential risks and use this new technique with caution.

Impact of coexisting coronary artery disease on the occurrence of cerebral ischemic lesions after carotid stenting

Background

Coronary artery disease (CAD) may coexist with extracranial carotid artery stenosis (ECAS), but the influence of CAD on procedure-related complications after carotid artery stenting (CAS) has not been well investigated. The study aimed to determine the impact of CAD on the occurrence of peri-CAS cerebral ischemic lesions on diffusion-weighted imaging (DWI) scanning.

Methods

Coronary angiography was performed within six months before CAS. DWI scanning was repetitively done within 1 week before and after CAS. Clinical outcome measures were stroke, angina, myocardial infarction and death within 30 days.

Results

Among 126 patients (69.5±9.0 years) recruited for unilateral protected CAS, 33 (26%) patients had peri-CAS DWI-positive lesions. CAD was noted in 79% (26 in 33) and 48% (45 in 93) of patients with and without peri-CAS DWI-positive lesions (OR, 4.0; 95% CI, 1.6–10.0; P = .0018), and the number of concomitant CAD on coronary angiography was positively correlated with the risk for peri-CAS DWI-positive lesions (P = .0032). In patients with no CAD (n = 55), asymptomatic CAD (n = 41) and symptomatic CAD (n = 30), the occurrence rates of peri-CAS DWI-positive lesions were 13%, 41% and 30% (P = .0048), and the peri-CAS stroke rates were 2%, 7% and 0% (P = .2120).

Conclusions

The severity of morphological CAD and the presence of either symptomatic or asymptomatic CAD are associated with the occurrence of peri-CAS cerebral ischemic lesions.

Heterogeneous cerebral vasoreactivity dynamics in patients with carotid stenosis

Cerebral vasoreactivity (CVR) can be assessed by functional MRI (fMRI) using hypercapnia challenges. In normal subjects, studies have shown temporal variability of CVR blood oxygenation level-dependent responses among different brain regions. In the current study, we analyzed the variability of BOLD CVR dynamics by fMRI with a breath-holding task in 17 subjects with unilateral carotid stenosis before they received carotid stenting. Great heterogeneity of CVR dynamics was observed when comparing BOLD responses between ipsilateral and contralateral hemispheres in each patient, especially in middle cerebral artery (MCA) territories. While some subjects (n=12) had similar CVR responses between either hemisphere, the others (n=5) had a poorly correlated pattern of BOLD changes between ipsilateral and contralateral hemispheres. In the latter group, defined as impaired CVR, post-stenting perfusion tended to be more significantly increased. Our data provides the first observation of divergent temporal BOLD responses during breath holding in patients with carotid stenosis. The development of collateral circulation and the derangement of cerebral hemodynamics can be detected through this novel analysis of the different patterns of BOLD changes. The results also help in prediction of robust increase of perfusion or hyperperfusion after carotid stenting.

CT-guided core needle biopsy of deep suprahyoid head and neck lesions

Objective

To evaluate the efficacy of computer tomography (CT)-guided core needle biopsy (CNB) in the diagnosis of deep suprahyoid lesions in patients with treated head and neck cancers.

Materials and Methods

Between December, 2003 and May, 2011, 28 CT-guided CNBs were performed in 28 patients with deep suprahyoid head and neck lesions. All patients had undergone treatment for head and neck cancers. Subzygomatic, paramaxillary, and retromandibular approaches were used. The surgical results, response to treatment, and clinical follow-up were used as the diagnostic reference standards.

Results

All biopsies yielded adequate specimens for definitive histological diagnoses. A specimen from a right parapharyngeal lesion showed atypia, which was deemed a false negative diagnosis. Diagnostic accuracy was 27/28 (96.4%). Two minor complications were encountered: a local hematoma and transient facial palsy. Between the 18 or 20 gauge biopsy needles, there was no statistical difference in the diagnostic results.

Conclusion

CT-guided core needle biopsy, with infrequent and minor complications, is an accurate and efficient method for the histological diagnosis of deep suprahyoid lesions in post-treated head and neck cancer patients. This procedure can preclude an unnecessary surgical intervention, especially in patients with head and neck cancers.

Large-area anodized alumina nanopore arrays assisted by soft ultraviolet nanoimprint prepatterning

Aluminium anodization under optimized conditions can naturally generate close-packed and aligned nanopore arrays, but the spatial extent of such regular pore arrangement is generally limited. Here we demonstrated the use of soft ultraviolet nanoimprint lithography to guide the formation of nanopores at specific locations, using an elastomer negative mold for the process. By anodizing at voltages which naturally led to the formation of pores with matching averaged interpore separation, pre-patterned triangular holes (diameter 100 nm, periodicity 350 nm) on aluminium thin films induced conformal growth of nanopores at pre-defined positions. In addition, pores in geometries other than close-packed patterns were prepared, with square pore arrangement being demonstrated in this work. The influence of the anodization voltage on the final pore formation was also studied. Our results illustrated the possibility to fabricate well-organized nanopore arrays with conditions far less stringent than those reported in literature, which has the potential to be adopted for applications where regular pore alignment are critical.

Impact of silent ischemic lesions on cognition following carotid artery stenting

OBJECTIVE

The occurrence of silent ischemic lesions (SILs) is a common finding after carotid artery stenting (CAS). This study aimed to evaluate the impact of SILs on cognitive functioning following CAS.

METHODS

The retrospective study separated 131 patients with unilateral carotid stenosis into three groups: medication only, MRI-evaluated CAS and CT-evaluated CAS, and compared the sociodemographic factors, post-CAS images and Mini-Mental State Examination scores performed before and 6-12 months after enrollment.

RESULTS

Seven minor strokes occurred in the 99 patients receiving CAS. SILs were detected in 12 of 55 patients with diffusion-weighted MR imaging (DWI) and in 3 of 37 patients with CT 1 week after CAS. In patients with DWI follow-up, the frequency of SILs was 8, 24, 43 and 60% in patients with 0-, 1-, 2- and 3-vessel coronary artery disease (p = 0.006). The frequency of SILs on DWI was 0, 32 and 33% in patients with improved, unchanged, or deteriorated cognitive functioning (p = 0.02). Such an association was not observed if based on SILs on CT or manifesting stroke.

CONCLUSION

The presence of coronary artery disease increases the risk for having post-CAS SILs, and the occurrence of SILs may be associated with cognitive changes after CAS.

Carotid stenting of asymptomatic and symptomatic carotid artery stenoses with and without the use of a distal embolic protection device

OBJECTIVE

The objective of this study was to evaluate the incidence of symptomatic and clinically silent embolic following carotid angioplasty and stent placement (CAS) with and without the use of an embolic protection device (EPD).

MATERIALS AND METHODS

Between January 2006 and April 2009, 76 patients with carotid stenosis underwent 79 CAS procedures (three patients had bilateral CAS). In this group, 44 of the 79 procedures were performed with an EPD, and 35 were performed without an EPD. In the EPD group, 26 treated hemispheres received pre- and post-operative diffusion-weighted MRI (DWI), and in the non-EPD group, 16 treated hemispheres received pre- and post-operative DWI.

RESULTS

All 79 procedures were technically successful without significant residual stenosis. In the EPD group, there were three symptomatic ischaemic events (6.8%), and 4 of the 26 (15.4%) treated hemispheres which received MRI showed new DWI lesions. In the non-EPD group, there was one symptomatic ischaemic event (2.9%), one mortality (2.9%) due to reperfusion injury with intracranial haemorrhage, and three of the 16 (18.8%) treated hemispheres which received MRI showed new DWL lesions.

CONCLUSIONS

The results of this retrospective analysis do not show demonstrable benefits of reducing new DWI lesions or major/minor ischaemic events after CAS with a filter protection device. Further investigations with more accurate risk-analysis strategies remain necessary in hopes of selecting patients most likely to benefit from the use of an embolic protection device.

Successful endovascular treatment of intractable epistaxis due to ruptured internal carotid artery pseudoaneurysm secondary to invasive fungal sinusitis

BACKGROUND

Mycotic pseudoaneurysm from the cavernous segment of the internal carotid artery (ICA) secondary to an invasive aspergillus sinusitis is rare. Surgical intervention with ICA ligation is generally accepted for most mycotic aneurysms or pseudoaneurysms. When presented with massive epistaxis due to a fungal aspergillus ICA invasion, mortality rates are high.

METHODS

We present the case of a 76-year-old man who developed intractable epistaxis due to a mycotic pseudoaneurysm arising from the cavernous segment of the right ICA.

RESULTS

The patient was successfully treated by endovascular embolization at the orifice of the pseudoaneurysm followed by the total ICA trapping technique using electrolytically Guglielmi detachable coils (GDCs) and injection of N-butyl-2-cyanoacrylate (n-BCA). The patient survived for 7 months but eventually died of urosepsis and cardiorespiratory failure.

CONCLUSION

Endovascular embolization is a feasible and life-saving approach for emergent management of massive intractable epistaxis secondary to a complicated invasive fungal sinusitis.

Validation of the jugular venous reflux animal model by three-dimensional time-of-flight MRA with a clinical scanner

BACKGROUND AND PURPOSE

A rat model of jugular venous reflux (JVR) is widely used in studies of cerebral arteriovenous fistula, cerebral venous hypertension and chronic cerebral hypoperfusion. However, methods to validate the effectiveness of the operation are needed.

METHODS

We performed neck 3-dimensional time-of-flight magnetic resonance angiography (MRA) with a clinical scanner in a rat model of JVR before and after the operation. High-resolution arterial angiography of the rat neck was acquired with maximum intensity projection.

RESULTS

In the JVR model, the success of the operation was validated by enhanced venous structures on MRA. The angiogram also provided information on the height of JVR and the status of other neck vessels.

CONCLUSIONS

In conclusion, neck 3-dimensional time-of-flight MRA is a useful noninvasive method for monitoring the blood flow in multiple cerebral vessels in this animal model. It also revealed the height of JVR, collateral development and changes in vessels over time in longitudinal studies. This information should be considered in the evaluation of the animal model.

Treatment of recurrent carotid cavernous fistula by direct puncture of a previously trapped internal carotid artery

Treatment of direct carotid cavernous fistulas has evolved from surgical ligation and trapping to endovascular techniques. Endovascular therapy allows occlusion of the fistula while preserving the parent carotid artery. The present report describes a case of direct carotid cavernous fistula that was initially treated with the trapping procedure 21 years earlier. The patient had a recurrent direct carotid cavernous fistula and was treated successfully with embolization by means of direct percutaneous puncture of the carotid artery above the trapped level. Direct puncture of the carotid artery is an alternative treatment in patients who lack safe access for direct carotid cavernous fistula embolization.

Traumatic internal carotid artery pseudoaneurysm mimicking sphenoid sinus tumor

Massive epistaxis following blunt craniofacial trauma should alert clinicians to possible traumatic internal carotid artery (ICA) aneurysm. This article describes a case of a 46-year-old female patient with traumatic ICA pseudoaneurysm presenting similar to a sphenoid sinus mass lesion. Massive bleeding occurred during the endoscopic procedure. Brain angiography revealed two lobulated ICA pseudoaneurysms over a cavernous segment. The patient successfully underwent endovascular stent assisted coil embolization. Timely diagnosis and treatment of the ICA psuedoaneurysm produced a favourable outcome.

Intestinal atresia of co-twin after spontaneous cessation of blood flow through an acardiac twin

A 33-year-old woman was diagnosed at 15 weeks gestation with a twin pregnancy complicated by an acardiac acephalic foetus. The patient opted for expectant management with close foetal surveillance. Serial ultrasonography showed polyhydramnios at 22 weeks gestation. However, subsequent scans over the next two weeks showed cessation of blood flow in the acardiac foetus, decreasing size of the foetal mass, as well as gradual resolution of the polyhydramnios. Subsequent follow-up was rather uneventful and she underwent an uncomplicated elective caesarean section at 35 weeks, resulting in a healthy 2,820 g girl. The baby was found to have intestinal atresia at birth. She underwent surgery successfully and was well when discharged. The possible causes and pathophysiology of intestinal atresia are discussed.