Deep Learning-Based Digital Subtraction Angiography Characteristics in Nursing of Maintenance Hemodialysis Patients.

This study is aimed at exploring the diagnostic value of digital subtraction angiography (DSA) based on faster region-based convolutional networks (Faster-RCNN) deep learning for maintenance hemodialysis (MHD) diseases and to provide a theoretical basis for clinical nursing. A total of 50 MHD patients who were clinically diagnosed in the Blood Purification Center were randomly divided into the control group and the experimental group (25 cases for each group). The control group was given routine nursing intervention, and the experimental group was given overall nursing intervention under the supervision of DSA. A faster RCNN multitarget detection network was constructed to analyze the average accuracy of various vascular structures in the test set. The self-rating anxiety scale (SAS) and self-rating depression scale (SDS) were used to evaluate the degree of anxiety and depression. The urine volume before and after the operation, local hematoma after a puncture, the incidence of complications, and nursing satisfaction were recorded. The results showed that the average accuracy of the vein, internal carotid artery, circle of Willis, venous sinus, and venous vessels was 0.876, 0.916, 0.994, 0.925, and 0.732, respectively. The success rate of surgery in the experiment group was higher than that in the control group, and the difference had statistical significance (P < 0.05). The SAS score and SDS score in the experimental group were significantly lower than those in the control group (P < 0.05). The total incidence rate of complications in the experimental group (16.00%) was significantly lower than that in the control group (44.00%) (P < 0.05). The satisfaction rate of the experimental group was significantly higher than that of the control group (P < 0.05). The Faster-RCNN model had the best effect in differentiating the circle of Willis and a poor effect in differentiating venous vessels. DSA based on Faster-RCNN can significantly improve the success rate of puncture in MHD patients. The implementation of holistic nursing intervention under its supervision can significantly reduce postoperative complications and improve patient satisfaction with nursing compared with routine nursing.

Clinical response to surgical decompression in atypical pediatric Bow Hunter's syndrome suggesting alternative pathophysiology: Case report.

Bow Hunter's syndrome is a rare cause of posterior circulation ischemia, produced by the mechanical and reversible occlusion of the vertebral artery during cephalic rotation. Diagnosis requires clinical suspicion and careful inspection of images with three-dimensional reconstruction. The study of choice is dynamic digital subtraction angiography (DSA). Treatment alternatives are: medical, surgical or endovascular. We report the case of an 8-year-old boy with recurrent infarctions of the posterior circulation secondary to the dissection of the vertebral artery, in association with an occipital bone spur. Dynamic DSA was negative. Conservative initial management was elected with cervical immobilization and anticoagulation, but due to persistence of symptoms, surgical decompression was decided. The patient did not repeat symptoms postoperatively and returned to his usual life. This is the first case reported to our knowledge of a surgical pediatric patient with asymptomatic atypical compression of VA secondary to BHS, whose dynamic angiography was negative, suggesting an alternative mechanism of the syndrome.

Interventional radiology management of extremity pseudoaneurysms: a pictorial essay.

Pseudoaneurysms are vascular abnormalities caused by a damaging force on an arterial wall, resulting in a persistent extravasation of blood into the surrounding tissue, which can be the result of infection, inflammation, trauma or any iatrogenic procedure. The incidence of extremity artery pseudoaneurysms is rising because of increased number of endovascular procedures. As a number of complications are associated with these false aneurysms, it is important to know the treatment modalities available. Ultrasound is the most common method of diagnosing extremity pseudoaneurysm because of their superficial location. Computed tomographic angiography is the next investigation of choice as it has three-dimensional capability and can help evaluate the vascular bed. Digital subtraction angiography is rarely used for diagnosis alone, and is used only when a therapeutic procedure is planned. Treatment of these pseudoaneurysms has shifted from open surgical procedures to minimally invasive treatment in recent years. The different techniques for tackling these lesions include ultrasound-guided compression, percutaneous thrombin or glue embolisation and endovascular coil or stent graft placement. In this pictorial essay, we review the different treatment modalities so that an interventional radiologist is aware of all the treatments he can offer when confronted with these lesions.

Utilization of Carbon Dioxide Angiography and Percutaneous Balloon Angioplasty for Treatment of Transplant Renal Artery Stenosis.

BACKGROUND: Transplant renal artery stenosis (TRAS) may lead to graft dysfunction and failure. Progressive deterioration of renal allograft function may be exacerbated by contrast-induced nephrotoxicity during iodine contrast administration for renovascular imaging of allografts. We present our institutional experience of endovascular management for TRAS using CO2 digital subtraction angiography (CO2-DSA) and balloon angioplasty to manage failing renal transplants. METHODS: Four patients with renal allografts from March 2017-May 2018 were referred for graft dysfunction and pending renal transplant failure. Indications for referral included refractory hypertension, decreasing renal functioning, and elevated renovascular systolic velocities. RESULTS: Median age of the four patients was 41.5 years (22-60 years). There were two male and female patients. Chronic hypertension and type 2 diabetes mellitus were the most common comorbidities. An average total of 75 mL of CO2 was used, supplemented with 17.4 mL of iodinated contrast. All patients had improvements in renal function following intervention with a mean decrease in systolic and diastolic blood pressure of 25.8% and 21.4%, respectively. We also observed a mean decrease of BUN by 13.6% and creatinine by 37.4%. Additionally, eGFR increased by 37.7%. All allografts survived after surgery, and only one patient required repeat angioplasty for recurrence. CONCLUSIONS: CO2-DSA with balloon angioplasty can be successfully utilized to salvage deteriorating kidney allograft function in patients with TRAS.

Estimation of central arterial pressure from the radial artery in patients undergoing invasive neuroradiological procedures.

BACKGROUNDS: Central arterial pressure can be derived from analysis of the peripheral artery waveform. The aim of this study was to compare central arterial pressures measured from an intra-aortic catheter with peripheral radial arterial pressures and with central arterial pressures estimated from the peripheral pressure wave using a pressure recording analytical method (PRAM). METHODS: We studied 21 patients undergoing digital subtraction cerebral angiography under local or general anesthesia and equipped with a radial arterial catheter. A second catheter was placed in the ascending aorta for central pressure wave acquisition. Central (AO) and peripheral (RA) arterial waveforms were recorded simultaneously by PRAM for 90-180 s. During an off-line analysis, AO pressures were reconstructed (AOrec) from the RA trace using a mathematical model obtained by multi-linear regression analysis. The AOrec values obtained by PRAM were compared with the true central pressure value obtained from the catheter placed in the ascending aorta. RESULTS: Systolic, diastolic and mean pressures ranged from 79 to 180 mmHg, 47 to 102 mmHg, and 58 to 128 mmHg, respectively, for AO, and 83 to 174 mmHg, 47 to 107 mmHg, and 60 to 129 mmHg, respectively, for RA. The correlation coefficients between AO and RA were 0.86 (p < 0.01), 0.83 (p < 0.01) and 0.86 (p < 0.01) for systolic, diastolic and mean pressures, respectively, and the mean differences - 0.3 mmHg, 2.4 mmHg and 1.5 mmHg. The correlation coefficients between AO and AOrec were 0.92 (p < 0.001), 0.87 (p < 0.001) and 0.92 (p < 0.001), for systolic, diastolic and mean pressures, respectively, and the mean differences 0.01 mmHg, 1.8 mmHg and 1.2 mmHg. CONCLUSIONS: PRAM can provide reliable estimates of central arterial pressure.

Short-Term Oral Sorafenib for Therapy of Intratumoral Shunts of Hepatocellular Carcinoma to Enable Intraarterial Treatment.

INTRODUCTION: Significant intratumoral shunts between tumor-supplying arteries and portal or liver veins are a contraindication for transarterial therapy of HCC because interventional treatment of these shunts is frequently insufficient. Sorafenib has anti-angiogenic effects and is indicated for palliative treatment of patients with HCC. Here, we report our experience with the use of sorafenib for the closure of intratumoral shunts in patients scheduled for transarterial therapy of HCC. MATERIALS AND METHODS: Three patients with HCC, aged 65, 82 and 79 years, exhibited a significant intratumoral shunting from tumor artery to portal (n = 1) or liver veins (n = 2). In all cases, intratumoral shunting had already been suspected based on pre-interventional CT angiography, and DSA confirmed the shunt. Oral sorafenib (800 mg/day) was administered for at least four weeks, only and specifically to occlude the shunt. Hereafter, patients were re-evaluated by CT and DSA. RESULTS: All patients tolerated the full prescribed dose for at least 4 weeks. In one case, therapy was prolonged with an adapted dose (400 mg/day) due to sorafenib-related hand-foot syndrome. After sorafenib treatment, CT and DSA confirmed a complete closure of intratumoral shunts for all patients. No tumor progression was observed. All three patients hereafter underwent successful transarterial treatment by TACE (n = 2) or TARE (n = 1) without complications. Progression-free survival according to mRECIST was 501, 397 and 599 days, respectively. CONCLUSION: Even short-term oral sorafenib seems to effectively close intratumoral shunts in patients with HCC and thus might enable transarterial treatment of these patients.

Tumor Hypervascularity and hand-foot-skin reaction predict better outcomes in combination treatment of TACE and Sorafenib for intermediate hepatocellular carcinoma.

BACKGROUND: To validate the robust predictive values of tumor vascularity and hand-foot-skin reaction (HFSR) in combination treatment of transarterial chemoembolization (TACE) and sorafenib for patients with intermediate hepatocellular carcinoma (HCC), and then select the potential candidates who would survive best from such treatment. METHODS: A total of 132 treatment-naive patients with intermediate HCC undergoing combination therapy of TACE and sorafenib were recruited between January 2010 and December 2014. The tumor vascularity was defined according to digital subtraction angiography (DSA) and HFSR was assessed by the national cancer institute common terminology criteria for adverse events (NCI-CTCAE). The Mann-Whitney U test was used to assess the correlation between vascularity and radiologic response; time to radiologic progression (TTP) and overall survival (OS) were evaluated using Kaplan-Meier techniques and compared by log-rank test; factors associated with them were evaluated using multivariate Cox regression analysis. RESULTS: During a median follow up of 17.3 months, it was revealed that hypervascularity and development of ≥2 grade of HFSR within 60 days after sorafenib initiation were favorable predictors for TTP (HR 0.378, p < 0.001; HR 0.627, p = 0.018) and OS (HR 0.499, p = 0.002; HR 0.555, p = 0.004). The median TTP and OS for patients with both were 12.2 and 29.1 months, which were better than patients with either of them (6.0 months, HR 1.74, p = 0.012; 16.5 months, HR 1.73, p = 0.021), as well as those with neither (2.9 months, HR 3.74, p < 0.001; 11.9 months, HR 3.17, p < 0.001). CONCLUSIONS: Tumor hypervascularity and development of ≥2 grade of HFSR within 60 days were favorable predictive factors for the combination treatment of TACE and sorafenib, with both of which the patients survived longest and might be the potential candidates.

Left Thalamus Arteriovenous Malformation Secondary to Radiation Therapy of Original Vermian Arteriovenous Malformation: Case Report.

A 70-year-old gentleman with history of hypothyroidism, hyperlipidemia, hypertension, and right superior cerebellar aneurysm presented to the neurosurgery service in 2008 with vertigo. Diagnostic cerebral angiography performed that year demonstrated a vermian arteriovenous malformations (AVM). The patient underwent stereotactic proton beam radiosurgery, which resulted in a decrease in flow and size of the lesion, and the patient was lost to follow-up. Now at the age of 80, the patient presented with acute gait instability. Cerebral angiogram demonstrated his stable vermian AVM and a new 1.1 cm AVM nidus in the region of the left posterior thalamus. Although AVMs are often described as congenital lesions, there is a growing body of literature suggesting that AVMs can grow, spontaneously regress, and even arise de novo in response to some insult. Understanding what leads to the growth, remodeling, regression, and hemorrhage of AVMs is crucial in order to better direct therapeutic endeavors. We would argue that this patient's AVM is secondary to endothelial cell damage from radiation therapy. Radiation can cause endothelial cell injury and upregulation of factors, such as vascular endothelial growth factor and transforming growth factor beta expression, which are implicated in AVM development pathways. We believe that this patient's new AVM is secondary to entrance radiation dosing affecting the thalamus during radiation therapy for the original vermian AVM.

Percutaneous Portal Vein Embolization Using a Simplified Sheathless 18-Gauge Trocar Needle Approach: Review of Efficacy and Safety.

PURPOSE: Portal vein (PV) embolization (PVE) is traditionally performed via a PV sheath with selective embolization of PV branches. Here, the efficacy and safety of PVE with the use of only an 18-gauge needle is reported. MATERIALS AND METHODS: Consecutive patients who underwent PVE from 2009 through 2017 were retrospectively reviewed. Forty-five patients (mean age, 60 y ± 7.6; 38 men) underwent 45 PVE procedures. Hepatocellular carcinoma, cholangiocarcinoma, and metastases accounted for 26 (58%), 13 (29%), and 6 (13%) patients, respectively. PVE was performed by puncturing a branch of right PV with an 18-gauge needle under US guidance. Via the same needle, direct portography was performed, followed by PVE with an N-butyl cyanoacrylate/Lipiodol mixture. Percentage increase of future liver remnant (FLR) volume and increase in ratio of FLR to total liver volume were estimated as measures of efficacy. Complications were reported according to Society of Interventional Radiology classification. Fluoroscopy time, procedure time, and dose-area product (DAP) were recorded. RESULTS: Technical success rate was 100%. The median DAP, fluoroscopy time, and procedure time were 74,387 mGy·cm2 (IQR, 90,349 mGy·cm2), 3.5 min (IQR, 2.10 min), and 24 min (IQR, 10.5 min). Among the 23 patients with complete CT volumetry data, mean increase in the ratio of FLR to total liver volume and percentage increase of FLR volume were 12.5% ± 7.7 and 50% ± 33, respectively. There were 3 minor complications (asymptomatic nonocclusive emboli in FLR) and 3 major complications (1 hepatic vein emboli, 1 subphrenic collection, and 1 hepatic infarct). CONCLUSIONS: PVE via a sheathless 18-gauge needle approach is feasible, with satisfactory FLR hypertrophy.

Imaging Diagnosis of Transient Ischemic Attack in Clinic and Traditional Chinese Medicine.

Neuroimaging plays a pivotal role in Transient Ischemic Attack (TIA). Generally, clinicians focus on the specific changes in morphology and function, but the diagnosis of TIA often depends on imaging evidence. Whereas Traditional Chinese Medicine (TCM) is concerned with the performance of clinical symptoms, they began to use imaging methods to diagnose TIA. CT and MRI are the recommended modality to diagnose TIA and image ischemic lesions. In addition, Transcranial Doppler sonography (TCD) and Digital Subtraction Angiography (DSA) are two acceptable alternatives for diagnosing TIA patients. This article elaborates the update of imaging modalities in clinic and the development of imaging modalities in TCM. Besides, multiple joint imaging technologies also will be evaluated whether enhanced diagnostic yields availably.

The Novel X-Ray Visible Zein-Based Non-adhesive Precipitating Liquid Embolic HEIE1_2017: An Exploratory Study.

PURPOSE: To investigate the novel zein-based non-adhesive precipitating liquid embolic HEIE1_2017. MATERIALS AND METHODS: Zein-based liquid embolics are an own class of embolization material. In this study, HEIE1_2017, a novel zein-based liquid embolic, was investigated. Visibility was assessed in vitro in CT and MRI phantoms, embolization characteristics were assessed in vivo in the kidneys of 12 pigs. Components of HEIE1_2017 were zein as occlusion material, ethanol as solvent, and iodized oil as radiopaque material. HEIE1_2017 was used in pure (HEI-PURE) and manually modified (HEI-MOD) form and compared with 6% ethylene vinyl alcohol copolymer (EVOH). Different radiological methods (CT, MRI, DSA, cone-beam CT, and micro-CT) and histopathologic analyses were applied to compare visibility and vascular occlusion patterns. RESULTS: In CT phantoms, all embolics were definitely visible as hyperdense materials. In MRI phantoms, signal-to-noise ratio was highest for HEI-PURE, followed by HEI-MOD and EVOH. In all kidneys, embolization procedures were technically successful and without complications. In DSA, all embolics were definitely visible during and after embolization. Only EVOH caused substantial artifacts in cone-beam CT and CT. In micro-CT and histopathology, HEI-PURE showed a homogeneous occlusion from segmental arteries to glomerular capillaries. HEI-MOD demonstrated the deepest vascular penetration (up to the level of peritubular capillaries), but with an inhomogeneous distribution. For EVOH, there was inhomogeneous vascular occlusion from segmental arteries to glomerular capillaries. CONCLUSION: HEIE1_2017 is a promising novel zein-based liquid embolic. Further preclinical and clinical studies with higher case numbers and long-term follow-up are needed to further assess the value of this embolic material.

Utility of the Virtual Liver Parenchymal Perfusion Area Using a Commercially Available Workstation in Transarterial Chemoembolization for Hepatocellular Carcinoma.

PURPOSE: To evaluate the accuracy of the virtual liver parenchymal perfusion area using a commercially available workstation and liver analysis software in conventional transarterial chemoembolization (cTACE) for hepatocellular carcinoma (HCC). MATERIALS AND METHODS: This method was retrospectively applied to 29 treated HCCs in 23 patients. The virtual embolic area (VEA) was estimated based on cone beam computed tomography during hepatic arteriography using a commercially available workstation and liver analysis software by two observer groups (group A: experts; group B: semi-experts). The real embolic area (REA) was defined as the area where iodized oil accumulated on computed tomography at 1 week after cTACE. The REA was estimated by each of the two groups, and the mean REA between the groups (mREA) was used as a standard reference. Agreement of volume and cross-sectional area in three orthogonal planes between the VEA and mREA were analyzed using intraclass correlation coefficients (ICCs) and Bland-Altman plots. RESULTS: The ICCs for volume between VEA and mREA were 0.97 and 0.88 for groups A and B, respectively, and those for cross-sectional area were 0.94 and 0.88 for the axial plane, 0.95 and 0.83 for the coronal plane, and 0.87 and 0.74 for the sagittal plane, respectively. Thus, the overall agreement was excellent, except for the sagittal imaging plane in group B. CONCLUSION: This method using a commercially available workstation and liver analysis software can be useful for estimating the embolic area in cTACE.

[Effect of foam sclerotherapy for the treatment of oropharyngeal venous malformation].

Objective: To evaluate the safety and efficacy of foam sclerotherapy with polidocanol for the treatment of venous malformation in the oropharynx. Methods: The clinical data of 21 children with venous malformation in the oropharynx treated by foam sclerotherapy were retrospectively analyzed. There were 10 males and 11 females, ranging in age from 1 month to 13 years, with a median age of 2.3 years. MRI was performed in all children, and the diagnosis was further confirmed by radiography. After general anesthesia, the oropharynx was exposed by opening device. Scalp acupuncture was used to pucture lesions and polidocanol foam was injected after the nidus was confirmed by digital subtraction angiography(DSA). The follow-up time ranged from 2-29 months, with a mean time of 15 months. The clinical symptoms, imaging data, therapeutic effects and postoperative complications were evaluated. Results: Total numbers of treatment were 52 times, 1-6 times/case; 13 cases were cured, 7 cases was relieved and no response in one case. Postoperative swelling in 13 cases, fever in 3 cases, local mucosal ulcer in 2 cases, difficult extubation in 2 cases. No nerve injury, swallowing function damage and cardiopulmonary accidents were found in all patients. Conclusion: Foam sclerotherapy with polidocanol in the treatment of venous malformation in the oropharynx is a safe and effective method.

Aggressive management of vasospasm with direct intra-arterial nimodipine therapy.

BACKGROUND: The conventional medical management of cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH) is associated with uncertainty of outcome and complications. AIMS AND OBJECTIVES: To examine the effect of direct intra-arterial nimodipine therapy on outcome in patients with delayed cerebral ischemia (DCI). SETTINGS AND DESIGN: The retrospective observational study was conducted at a single neurosurgical unit and interventional neuroradiolgy suite of a center managing SAH. MATERIALS AND METHODS: Data analysis of SAH managed surgically during the period from January 2014 through October 2015 was performed. Any decline in the neurological status on clinical examination, such as consciousness, motor and speech deficits, without other identifiable causes such as hydrocephalus, hyponatremia, seizure, intracranial hematoma, or infection, was used to define the presence of DCI. Patients with suspected DCI underwent computed tomography (CT) scan of the head followed by angiography. When vasospasm was detected in the absence of any major arterial territory infarct, the patients were managed with intra-arterial nimodipine therapy. The outcome at discharge was assessed. STATISTICAL ANALYSIS: Mid-P exact, two-tailed P value was used for categorical variables. RESULTS:: A total of 106 patients underwent surgical clipping of an aneurysm following SAH. DCI was diagnosed in 26 (24.5%) patients. Twenty three (88.5%) patients underwent intra-arterial nimodipine therapy. Angiographic response was seen in 22 (95.7%) patients and clinical response in 20 (87%) patients. At discharge, 19 patients (73.1%) with vasospasm had a favorable outcome. There was no significant difference in the outcome of patients with or without vasospasm. CONCLUSIONS: Aggressive management with intra-arterial nimodipine therapy is effective in preventing disability caused by DCI.

Higher dose intra-arterial milrinone and intra-arterial combined milrinone-nimodipine infusion as a rescue therapy for refractory cerebral vasospasm.

Background Cerebral vasospasm (CV) is a major cause of delayed morbidity and mortality in patients with subarachnoid hemorrhage (SAH). Various cerebral protectants have been tested in patients with aneurysmal SAH. We aimed to research the success rate of treatment of CV via intra-arterial milrinone injection and aggressive pharmacological therapy for refractory CV. Methods A total of 25 consecutive patients who received intra-arterial milrinone and nimodipine treatment for CV following SAH between 2014 and 2017 were included in the study. Patients who underwent surgical clipping were excluded. Refractory vasospasm was defined as patients with CV refractory to therapies requiring ≥3 endovascular interventions. Overall, six patients had refractory CV. Long-term neurological outcome was assessed 6-18 months after SAH using a modified Rankin score and Barthel index. Results The median modified Rankin scores were 1 (min: 0, max: 3) and Barthel index scores were 85 (min: 70, max: 100) From each vasospastic territory maximal 10-16 mg milrinone was given to patients; a maximum of 24 mg milrinone was given to each patient in a session and a maximum of 42 mg milrinone was given to a patient in a day. Both milrinone and nimodipine were given to three patients. There was a large vessel diameter increase after milrinone and nimodipine injections. No patient died due to CV; only one patient had motor dysfunction on the right lower extremity. Conclusion Higher doses of milrinone can be used effectively to control refractory CV. For exceptional patients with refractory CV, high dose intra-arterial nimodipine and milrinone infusion can be used as a rescue therapy.

Endovascular occlusion of pial arteriovenous macrofistulae, using pCANvas1 and adenosine-induced asystole to control nBCA injection.

Background In large-caliber pial macrofistulae (pMF), the combination of high blood flow velocity and large efferent artery diameter makes control over the endovascular vessel occlusion difficult and may result in the inadvertent venous passage of occlusive devices or embolic agents. Case descriptions Patient 1: A 27-year-old man presented with headache and ataxia. An infratentorial pMF supplied by both superior cerebellar arteries with venous ectasia was found. The first treatment attempt using balloons and coils failed since the position of either device could not be controlled because of a distal diameter of the feeding artery of 8 mm. In a second session a pCANvas1 (phenox) was deployed at the level of the arteriovenous connection and adenosine-induced asystole allowed the controlled injection of nBCA/Lipiodol with partial occlusion of the pMF. A remaining arteriovenous shunt was occluded under asystole in a third session. The procedures were well tolerated, the patient returned to normal and DSA confirmed the occlusion of the fistula. Patient 2: A 13-year-old boy with hereditary hemorrhagic teleangiectasia presented with an intracerebral hemorrhage from an aneurysm of the left MCA. Twelve weeks after the aneurysm treatment a feeding MCA branch (diameter 4.5 mm) of a right frontal pMF was catheterized. The macrofistula was occluded by deployment of a pCANvas1, followed by the injection of nBCAl/Lipiodol under adenosine-induced asystole. Conclusion pCANvas1 and adenosine-induced asystole allow a controlled injection of nBCA/Lipiodol for the endovascular occlusion of high-flow pMF without venous passage of the embolic agent.

Delayed symptomatic haemorrhage from the remnants of a thalamic arteriovenous malformation after previous angiographic cure with radiotherapy.

In 1995 a 16-year old girl was diagnosed with a large left thalamic AVM that was considered unsuitable for microsurgical resection and was treated with radiotherapy twice, which led to angiographic cure. She re-presented 19 years after initial treatment with a symptomatic acute thalamic haemorrhage. Her digital subtraction angiography was negative for arterio-venous shunting. MRI/MRA showed cystic change with adjacent contrast enhancement in the region of the previously irradiated arteriovenous malformation. The patient underwent an interhemispheric transcallosal resection of the left thalamic haemorrhagic lesion via a contralateral craniotomy. Intra-operatively there was a cystic cavity filled with blood products in association with thrombosed, calcified vessels as well as actively filling vessels. Histologically there were aggregated abnormal blood vessels with a dilated lumen and surrounded by brain parenchyma. Some of the vessel walls were thickened with fibrosis and some were arterialised with presence of elastin fibres. Potential mechanisms for the delayed haemorrhage are discussed.

ω-3 Fatty Acids Ethyl Esters Suppress Cerebral Vasospasm and Improve Clinical Outcome Following Aneurysmal Subarachnoid Hemorrhage.

OBJECTIVE: Occurrence of cerebral vasospasm after onset of aneurysmal subarachnoid hemorrhage (SAH) is a critical factor determining clinical prognosis. Eicosapentaenoic acid and docosahexaenoic acid, both ω-3 fatty acids (ω-3FA), can suppress cerebral vasospasm, and docosahexaenoic acid can relax vessel vasoconstriction and have neuroprotective effects. We investigated whether administration of ω-3FA prevented cerebral vasospasm occurrence and improved clinical outcomes after aneurysmal SAH. METHODS: From 2012 to 2015, 100 consecutive patients with aneurysmal SAH were divided into 2 periods. Between 2012 and 2013 (control period), 45 patients received standard management. Between 2014 and 2015 (ω-3FA period), 55 patients were prospectively treated with additional ω-3FA. Occurrence of cerebral vasospasm, occurrence of cerebral infarction caused by vasospasm, and modified Rankin Scale scores at 30 days and 90 days after onset of SAH for each period were evaluated and compared. RESULTS: The frequency of angiographic cerebral vasospasm in the ω-3FA period was significantly lower than in the control period (12 patients vs. 23 patients, P = 0.004). The frequency of new infarction caused by vasospasm in the ω-3FA period was also significantly lower than in the control period (5 patients vs. 14 patients, P = 0.011). There was a significant difference in modified Rankin Scale scores at 90 days after onset of SAH between the groups (P = 0.031). No adverse events were associated with ω-3FA administration. CONCLUSIONS: Administration of ω-3FA after aneurysmal SAH may reduce the frequency of cerebral vasospasm and may improve clinical outcomes.