Bone mineral density, turnover, and microarchitecture assessed by second-generation high-resolution peripheral quantitative computed tomography in patients with Sheehan's syndrome.

Sheehan's syndrome (SS) is a rare but well-characterized cause of hypopituitarism. Data on skeletal health is limited and on microarchitecture is lacking in SS patients. PURPOSE: We aimed to explore skeletal health in SS with bone mineral density (BMD), turnover, and microarchitecture. METHODS: Thirty-five patients with SS on stable replacement therapy for respective hormone deficiencies and 35 age- and BMI-matched controls were recruited. Hormonal profile and bone turnover markers (BTMs) were measured using electrochemiluminescence assay. Areal BMD and trabecular bone score were evaluated using DXA. Bone microarchitecture was assessed using a second-generation high-resolution peripheral quantitative computed tomography. RESULTS: The mean age of the patients was 45.5 ± 9.3 years with a lag of 8.3 ± 7.2 years prior to diagnosis. Patients were on glucocorticoid (94%), levothyroxine (94%), and estrogen-progestin replacement (58%). None had received prior growth hormone (GH) replacement. BTMs (P1NP and CTX) were not significantly different between patients and controls. Osteoporosis (26% vs. 16%, p = 0.01) and osteopenia (52% vs. 39%, p = 0.007) at the lumbar spine and femoral neck (osteoporosis, 23% vs. 10%, p = 0.001; osteopenia, 58% vs. 29%, p = 0.001) were present in greater proportion in SS patients than matched controls. Bone microarchitecture analysis revealed significantly lower cortical volumetric BMD (vBMD) (p = 0.02) at the tibia, with relative preservation of the other parameters. CONCLUSION: Low areal BMD (aBMD) is highly prevalent in SS as compared to age- and BMI-matched controls. However, there were no significant differences in bone microarchitectural measurements, except for tibial cortical vBMD, which was lower in adequately treated SS patients.

Sex differences in cognitive function among people with HIV-1 clade C infection in Northern India.

Human immunodeficiency virus-1 (HIV-1) clade C is the most prevalent form of HIV-1 comprising nearly 46% of global infections and is the dominant subtype in India. Despite its predominance, the impact of HIV-1 clade C infection on cognitive function has been understudied in comparison with other subtypes, notably clade B, which is primarily found in Europe and North America. Few studies have assessed cognitive impairment in antiretroviral therapy (ART) naïve men and women with HIV-1 clade C infection. In this study conducted in Northern India, differences in neuropsychological functioning were compared between 109 participants (70 men, 39 women) with untreated HIV-1 clade C infection and 110 demographically matched healthy controls (74 men, 36 women). A comprehensive neuropsychological battery was used to examine depression, self-assessment of functioning, and cognitive performance in six domains of functioning. Group differences were assessed by HIV-1 status and sex, controlling for age and education. Results indicated that cognitive deficits were substantially greater among male participants with HIV-1 clade C compared to male controls in all domains of cognitive functioning; in contrast, women with HIV-1 clade C had only minor deficits compared to healthy female participants. In addition, a larger proportion of men with HIV-1 clade C exhibited high levels of depression than women with HIV-1 clade C. These findings suggest that untreated HIV-1 clade C infection in men can have debilitating effects on neuropsychological function and depression, and stress the importance of facilitating rapid access to treatment to reduce the impact of HIV-1 infection.

Cranio-facial bones evaluation based on clinical CT data for sex determination in Northwest Indian population.

The skull and pelvis have been the first choice of bones for determination of unknown human remains. The goal of the present study was to derive discriminant function equations by using clinical CT scan data of cranio-facial bones for sex determination in Northwest Indian population. This study was conducted at Department of Radiology, by collecting the retrospective data of CT scan of 217 samples. In the data, 106 were males and 111 were females in the age group between 20 and 80 years. The total number of parameters under investigation were 10. All the selected variables were sexually dimorphic and showed significant values. 91.7% of original grouped cases were correctly classified to their sex category. The TEM, rTEM and R were under the acceptable limits. The univariate, multivariate and stepwise discriminant function analysis recorded an accuracy of 88.9%, 91.7% and 93.6% respectively. Multivariate direct discriminant function analysis stepwise method yielded the highest level of accuracy in differentiating males and females. All the variables reflected statistically significant difference between males and females (p less than 0.001). The best single parameter with highest level of sexual dimorphic trait was length of cranial base. This study aims to provide sex assessment using clinical data of CT scan in Northwest Indian population by incorporating the BIOFB cranio-facial parameter. The morphometric measurements taken on CT scan images can be utilized by forensic experts in identification process.

Clinicoradiological Profile of COVID-19-Associated Rhino-Orbital Cerebral Mucormycosis with a Focus on Computed Tomography: A Clinical Case Series and Review.

COVID-19-associated rhino-orbital cerebral mucormycosis (ROCM) has a rapidly evolving course with high morbidity and mortality. We describe imaging features of COVID-19-associated ROCM based on noncontrast computed tomography (NCCT). This retrospective single-center observational study included 50 patients with COVID-19 from January 1, 2021 to June 30, 2021 who subsequently developed ROCM confirmed by fungal culture studies. All patients underwent NCCT of the paranasal sinuses as the diagnostic workup. The involvement of the nasal cavity, paranasal sinuses, orbits, and intracranial cavity was identified and graded. The ethmoid sinuses were most commonly involved [right (n = 46 of 50) > left (n = 45 of 50)], followed by the maxillary, sphenoid, and frontal sinuses. Thinning and erosions of the hard palate were noted in 18% of patients (n = 9), whereas 34% (n = 17) showed dehiscence of the lamina papyracea. Retromaxillary fat stranding was noted in 68% of patients (n = 34). Severe ethmoid sinusitis was associated significantly with ipsilateral pterygopalatine fossa involvement. The extraocular muscles were involved in 64% of patients (n = 32), with 84% (n = 42) showing orbital fat stranding. Proptosis of the affected eye was seen in 66% of patients, optic nerve involvement in 52%, and irregularity of globe contour in 12% (n = 6). The cavernous sinuses were affected in 10% of patients (n = 5), with three of them having temporal infarcts. COVID-19-associated ROCM is an acute, invasive fungal disease characterized by multisinus involvement, often with orbital and intracranial extension. Bilateral involvement with rapid progression should alert one to underlying COVID-19 disease.

Heavy and less common metals in rainwater and the kinetics of the oxidation of hydrogen sulfide by oxygen in rainwater medium.

As a sequel to our recent study on the oxidation by O2, i. e., autoxidation of dissolved hydrogen sulfide, H2S, in aqueous medium, we present here the results of a similar study in rain water medium. The rainwater sampling was done sequentially for four years (2016-2019). In all 67 samples of rainwater were collected on event basis during monsoon period (June-October) in and around the Campus of University of Rajasthan, Jaipur (26°50̛ N-75°52̛ E), which is situated in a semi-arid region adjacent to the Thar Desert in the North-Western part of the India having an annual average rainfall of 54 cm. ICP-MS technique was used in the analysis of rainwater and more than 30 metals were detected, which included transition metals, rare earths, less common metals. Beryllium, vanadium, silver, selenium, manganese, cerium, gallium, yttrium, barium, cesium, copper, rubidium, arsenic, lanthanum, cadmium, lead, uranium and bismuth were common to all rain water samples.H2S oxidation by dissolved oxygen was studied in rainwater as well as in laboratory water media for comparison. The kinetics rate law was: -d[O2]/dt = k1K1[H+][S][O2]t/( [H+]2 + K1[H+] + K1K2), where K1 is first dissociation constant of H2S and k1 is the rate constant for the dominant reaction step:HS- + O2 → products.

Radiological Parameters for Gamma Knife Radiosurgery.

Accurate lesion targeting is the essence of stereotactic radiosurgery. With the currently available imaging modalities, scanning has become quick and robust providing a high degree of spatial resolution resulting in optimal contrast between normal and abnormal tissues. Magnetic resonance imaging (MRI) forms the backbone of Leksell radiosurgery. It produces images with excellent soft tissue details highlighting the target and surrounding "at-risk" structures conspicuously. However, one must be aware of the MRI distortions that may arise during treatment. Computed tomography (CT) has quick acquisition times giving excellent bony information but inferior soft tissue details. To avail benefits of both these modalities and overcome their individual fallacies and shortcomings, they are often co-registered/fused for stereotactic guidance. Vascular lesions like an arteriovenous malformation (AVM) are best planned with cerebral digital subtraction angiography (DSA) in conjunction with MRI. In specific cases, specialized imaging methods like magnetic resonance (MR) spectroscopy, positron emission tomography (PET), magneto-encephalography (MEG), etc., may be added to the treatment planning for stereotactic radiosurgery (SRS).

Role of Diffusion-Weighted Magnetic Resonance Imaging for Characterization of Mediastinal Lymphadenopathy.

BACKGROUND: To assess the diagnostic performance of diffusion-weighted (DW) magnetic resonance imaging (MRI) in the characterization of mediastinal lymph nodes and compare them with morphological parameters. METHODS: A total of 43 untreated patients with mediastinal lymphadenopathy underwent DW and T2 weighted MRI followed by pathological examination in the period from January 2015 to June 2016. The presence of diffusion restriction, apparent diffusion coefficient (ADC) value, short axis dimensions (SAD), and T2 heterogeneous signal intensity of the lymph nodes were evaluated using receiver operating characteristic curve (ROC) and forward step-wise multivariate logistic regression analysis. RESULTS: The ADC of malignant lymphadenopathy was significantly lower (0.873 ± 0.109 × 10-3 mm2/s) than that of benign lymphadenopathy (1.663 ± 0.311 × 10-3 mm2/s) (p = 0.001). When an ADC of 1.0955 × 10-3 mm2/s was used as a threshold value for differentiating malignant from benign nodes, the best results were obtained with a sensitivity of 94%, a specificity of 96%, and an area under the curve (AUC) of 0.996. A model combining the other three MRI criteria showed less sensitivity (88.9%) and specificity (92%) compared to the ADC-only model. CONCLUSION: The ADC was the strongest independent predictor of malignancy. The addition of other parameters failed to show any increase in sensitivity and specificity.

Asymmetry in cerebral perfusion from circle of Willis arterial variations in normal population.

BACKGROUND: Angiographic and cadaveric studies have evidenced variations in the circle of Willis (CoW). Age-related changes in cerebral hemodynamics may be attributable to vascular variations. OBJECTIVES: The objective is to assess interdependence of completeness of CoW with age using non-invasive MRA and cerebral perfusion using arterial spin labeling (ASL). METHODS: This single-center, prospective study segregated 189 subjects into three groups: ≤5, 5 to 18, and >18 years. Angiographic (complete CoW and vascular asymmetry index) using TOF and contrast-enhanced- (CE-) MRA, and perfusion (perfusion asymmetry index) data using ASL were obtained. RESULTS: One hundred and six (56.08%) subjects showed complete CoW on TOF and 100 (52.91%) on CE-MRA. Anterior and posterior collateral pathways were more prevalent in the younger population. Completeness of CoW decreased with increasing age, group 1 (54/60, 90% TOF; 51/60, 85% CE), group 2 (39/64, 60% TOF; 37/64, 56.92% CE), and group 3 (13/65, 20.31% TOF; 12/65, 18.75% CE); p-value < .0001. A statistically significant decrease in cerebral and cerebellar perfusion with increasing age was seen. Cerebellar to frontal perfusion change was higher in group 1. Fetal posterior cerebral artery (PCA) led to ipsilateral low and contralateral hyperperfusion flow asymmetries between occipital lobes. CONCLUSIONS: This study shows that a complete CoW is commoner in pediatrics than adults and with increasing age, the completeness of CoW decreases paralleled by decrease in cerebral and cerebellar perfusion. There is age-related shift of perfusion from hindbrain to forebrain and the regression of PCoA occurs with increasing age leading to alterations in cerebral perfusion and hemodynamics.

Complex neurocysticercosis lesions on imaging: Explained through correlative histomorphology.

OBJECTIVES: Neurocysticercosis, the commonest neuro-parasite, sometimes presents as complex ring enhancing lesion causing diagnostic dilemma. We aim to establish radio-histo-morphological equivalents of early events in degeneration of the parasite to explain such imaging phenotypes. METHODS: We compared patterns of degeneration in 23 randomly selected complex NCC on MRI with histo-morphology in 30 cysts obtained from an unrelated post mortem brain. RESULTS: The anatomy of the parasite and the degenerative patterns of the scolex (hydropic changes, calcification, evagination, and fragmentation) and the cyst wall (undulation, accessory loculi, and frank disruption) were well demonstrated on both. The intact scolex remarkably resembled head of intestinal Taenia. The complex lesions were conglomeration of multiple communicating cysts with a single parent cyst and multiple daughter cysts. The parent cysts contained a solitary variably degenerated scolex, had thicker walls and associated chronic inflammation. The remaining cysts of the lesion complex contained no scolex, had poorly organized walls, turbid contents, and florid perilesional enhancement with leakage of contrast. Three lesions assumed a multi-cystic pseudo-tumorous pattern, of which two resolved into solitary calcific remnants on follow up. CONCLUSION: Complex lesion in NCC result from degeneration of solitary parasite with perilesional gliosis, surrounded by multiple non-larval daughter cysts inciting acute intra and perilesional inflammation due to enhanced antigenic challenge. Possibly, attempted abortive asexual reproduction by the cellulose cyst as a preterminal event results in a "limited Racemose like transition." Correct interpretation has diagnostic and therapeutic implications as active lesions and their fibrocalcific residue may have greater epileptogenic potential.

Cross-sectional analysis of whole-brain microstructural changes in adult patients with bipolar and unipolar depression by diffusion kurtosis imaging.

RATIONALE AND OBJECTIVES: More than half of the bipolar depression (BD) subjects are misdiagnosed as unipolar depression (UD) due to lack of objective diagnostic criteria. We aimed to identify microstructural neuronal changes differentiating BD from UD groups using diffusion kurtosis imaging (DKI). The objective of the study is to identify an objective neuro-imaging marker to differentiate BD from UD. MATERIALS AND METHODS: A prospective, cross-sectional study included total of 62 subjects with diagnosis of bipolar depression (n = 21), unipolar depression (n = 21), and healthy controls (n = 20). All subjects underwent diffusion-weighted imaging (b = 0,1000,2000) of the whole brain on 3-Tesla MR scanner. DKI data was analyzed using 189 region whole-brain atlas. Eight diffusion and kurtosis metrics including mean diffusivity (MD), axial diffusivity (AD), radial diffusivity (RD), fractional anisotropy (FA), mean kurtosis (MK), axial kurtosis (AK), radial kurtosis (RK), and kurtosis fractional anisotropy (FKA) were measured against these 189 regions. Principle component analysis (PCA) was utilized to identify the most significant regions of the brain. ANOVA with post hoc tests was used for analyzing these regions. RESULTS: BD group showed increased MD, RD, decreased AK at the left amygdala and decreased MK and RK at the right hemi-cerebellum. UD group showed increased MK and RK at the right external capsule; and increased AK, MK, and RK at the right amygdala. CONCLUSION: The right and left amygdala, right external capsule, and right hemi-cerebellum showed microstructural abnormalities capable of differentiating BD and UD groups. Diffusion imaging especially DKI can aid in management of depression patients.

Adapting to transradial approach in cerebral angiography: Factors influencing successful cannulation.

BACKGROUND: To evaluate factors that influence the successful cannulation of intracranial vessels using a transradial approach. METHODS: A total of 61 transradial diagnostic angiograms were evaluated in a tertiary care center from July 2020 to December 2021. We evaluated the learning curve and aortic arch vessel factors that may influence the cannulation of intracranial major vessels using a transradial approach. RESULTS: Learning curve for the procedure was established after 21 cases. We were successful in cannulating the supra-aortic arteries except in 4 cases where we were unable to cannulate the left VA (vertebral artery). Significant positive correlation was seen between time to Sim (Simmons curve) formation and aortic arch diameter (p = .002). Significant positive correlation was also seen between left VA take-off angle and time to cannulate left VA (p = .001) and negative correlation was noted between left CCA (common carotid artery) take-off angle and time to cannulate left CCA (p = .001). CONCLUSION: Transradial approach is a feasible and safe approach for performing cerebral angiography. Multiple factors can influence the procedure time and successful cannulation of intracranial vessels. With the availability of radial specific hardware in the future, procedural success and time taken to complete the procedure may improve.

Serum Calcitonin Gene-Related Peptide Is Elevated in Patients With Migraine and Ophthalmoplegia.

BACKGROUND: There is ongoing debate about whether the oculomotor (III), trochlear (IV), or abducens (VI) nerve paresis in patients with migraine is directly attributable to migraine (ophthalmoplegic migraine [OM]) or is due to an inflammatory neuropathy (recurrent painful ophthalmoplegic neuropathy [RPON]). As migraine is associated with elevated serum calcitonin gene-related peptide (CGRP) levels, we studied serum CGRP levels among patients with OM/RPON to determine whether they are elevated during and between attacks. This is the first study assessing CGRP levels in the serum of patients with OM/RPON. METHODS: The aim of this case-control study was to assess serum CGRP levels in patients with ophthalmoplegia and a headache consistent with migraine according to ICHD-3 criteria. Serum CGRP levels were measured during the ictal and interictal phases in 15 patients with OM/RPON and compared with age-matched and sex-matched controls without migraine (12 patients). RESULTS: The median serum CGRP levels were significantly elevated ( P = 0.021) during the ictal phase (37.2 [36.4, 43.6] ng/L) compared with controls (32.5 [30.1, 37.3] ng/L). Serum CGRP levels during the attack correlated with the total duration of ophthalmoplegia. A CGRP level of 35.5 ng/L in the ictal phase of the attack had a sensitivity of 86.7% and specificity of 75.0% in diagnosing a patient with OM/RPON. CONCLUSIONS: Elevated serum CGRP levels during the ictal phase of OM/RPON favor migraine as the underlying cause of episodic headache with ophthalmoplegia.

Advanced multiparametric MRI-based scoring for isocitrate dehydrogenase mutation prediction of gliomas.

Purpose: To propose an advanced multiparametric magnetic resonance imaging (MRI)-based scoring system and evaluate its diagnostic accuracy with respect to the isocitrate dehydrogenase (IDH) mutation status of gliomas. Material and methods: This prospective observational study included 50 consecutive patients with suspected gliomas, enrolled for pre-operative MRI. The exclusion criteria were previous surgery, biopsy, or chemo/radiotherapy and contraindications to the gadolinium-based contrasts or MRI acquisition. A standardized brain-MRI protocol using a 3-Tesla machine and 16-channel head coil consisted of pre-contrast axial-T2WI, FLAIR, DTI, 3D-ASL perfusion, SWI, 3D-T1WI, and post-contrast axial-DSC perfusion followed by 3D-T1WI and MR spectroscopy. ROIs were drawn from the tumoral centre, periphery, and peritumoral oedema (3 ROIs for each) followed by normalization using the ROIs over the contralateral normal white matter. The cut-off values for the statistically significant (p <0.05) continuous variables were derived by drawing receiver operating characteristic (ROC) curves. A 7-point "glioma-score" was derived from the 3 categorical (T2/FLAIR-mismatch, contrast enhancement, and intratumoral susceptibility signals) and 4 continuous ROI-based variables (ADC, FA, ASL-CBF, and DSC-CBV). Results: The predictability of IDH mutant status using the multiparametric advanced MRI-based glioma score was statistically significant (sensitivity = 69.23%, specificity = 95.65%, PPV = 94.74%, NPV = 73.33%). A glioma score of more than 4.5 out of 7 predicted the IDH-mutation status with higher specificity and sensitivity compared to each of the individual imaging variables. Conclusions: The advanced multiparametric MRI-based glioma score can predict the IDH-mutation status with high statistical significance.

Long-term hepatic and cardiac health in patients diagnosed with Sheehan's syndrome.

PURPOSE: Sheehan's syndrome (SS) is characterised by chronic pituitary insufficiency following a vascular insult to the pituitary in the peripartum period. There is a lack of substantial evidence on the long-term hepatic and cardiac consequences in these patients, following hormone replacement. METHODS: Patients with a diagnosis of SS were recruited for the study. Detailed clinico-biochemical and radiological evaluation were performed in all patients (n = 60). Hepatic and cardiac complications were assessed using fibroscan and echocardiography (2D speckle-tracking) respectively, in a subset of patients (n = 29) as well as age-and BMI-matched controls (n = 26). Controlled attenuation parameter (for steatosis) and liver stiffness measurement (for fibrosis) were used to define non-alcoholic fatty liver disease (NAFLD). Diastolic cardiac function was evaluated using standard criteria and systolic function by ejection fraction and global longitudinal strain (GLS). RESULTS: The mean age of the cohort was 42.7 ± 11.6 years. Multiple (≥ 2) hormone deficiencies were present in 68.8% of patients, with hypothyroidism (91.4%), hypocortisolism (88.3%), and growth hormone (GH) deficiency (85.7%) being the most common. At a mean follow-up of 9.8 ± 6.8 years, NAFLD was present in 63% of patients, with 51% having severe steatosis, which was predicted by the presence of GH deficiency and higher body mass index. Though the ejection fraction was similar, increased left ventricular GLS (18.8 vs. 7.7%) was present in a significantly higher number of patients versus controls. CONCLUSION: NAFLD, especially severe hepatic steatosis, is highly prevalent in SS. Subclinical cardiac systolic dysfunction (impaired GLS) is also more common, but of mild intensity.

The Profile of Epilepsy and its characteristics in Children with Cerebral Palsy.

PURPOSE: To determine the characteristics of epilepsy in children with Cerebral Palsy (CP) visiting the Pediatric Outpatient Department (OPD) of a tertiary care hospital. METHODS: This cross-sectional study was carried out at a tertiary care pediatric hospital. All children with CP aged between 1 and 12 years seen at this hospital during an 18 months period (January 2018 to July 2019) were included. Children with CP who had seizures were studied in detail. Seizure semiologies were classified according to the International League Against Epilepsy (ILAE) 1981 and 2017 classifications. The severity of seizures was assessed with the Early Childhood Epilepsy Severity Scale (E-Chess). Functional impairment was characterised using the Gross Motor Function Classification System (GMFCS) score. RESULTS: Of 300 children with CP, 207 (69%) were male and 93 (31%) female. The mean age was 45.17±31.12 months. Seizures were present in 79 (26%) children. 89.9% of children had drug-responsive epilepsy, and 10.1% had refractory epilepsy. Seizures were present in 30.4% of children with a spastic hemiplegia CP subtype, 28.7% with spastic quadriplegia, 26.3% with spastic diplegia, 24% with mixed type CP, and 6.3% with dyskinetic CP. On E-Chess assessment, the median score was 8 (4-14). The majority had poor Gross Motor Function Classification System (GMFCS) scores (>III). CONCLUSION: The prevalence of epilepsy in the studied population of children with CP was 26%. The highest incidence of seizures was in the spastic hemiplegia subtype (30.4%). The severity of cortical damage is positively correlated with the risk of having epilepsy. The primary determinant of severity of the GMFCS score was the type of CP and not the presence or absence of epilepsy.

Neuromyelitis Optica Spectrum Disorders in North Indian Population: Experience from a Tertiary Care Center.

Introduction: To understand neuromyelitis optica spectrum disorders (NMOSDs) better we need to study them in different populations. This prospective study was conducted to characterize clinical, serological, radiological, and therapeutic profile of NMOSDs in a North Indian population. Materials and Methods: This study included 81 patients with NMOSDs. All patients underwent detailed history and examinations and were followed at 3 monthly intervals. They were evaluated using standard investigations including gadolinium-enhanced magnetic resonance imaging (MRI) of the brain and spine with thin section optic nerve cuts and treated as per the standard guidelines. Data were recorded meticulously. Results: The mean age was 33.7 ± 13.4 years. The mean age at disease onset was 31.2 ± 13.5 years. Female-to-male ratio was 1.9:1. About 32.1% of patients presented with optic neuritis (ON), 56.8% with transverse myelitis (TM), and 11.1% with both ON and TM. The mean time from disease onset to diagnosis was 16.17 ± 23.09 months. Muscle atrophy, Lhermitte symptom, and tonic spasms were common. Foster-Kennedy syndrome-like presentation was seen in 8.6%. NMO antibodies were positive in 41 patients. MRI revealed involvement of <4 vertebral segments in 16.4% of patients with TM. Patients were managed as per standard guidelines. The mean follow-up duration was 15.3 ± 6 months. Approximately 88.9% had good functional outcome. Conclusion: NMOSDs are a common cause of demyelinating illnesses in Northern India. The response to treatment is excellent and most patients recover without residual disability.

Endovascular coiling of recurrent trapped pseudoaneurysm of petrous ICA across the distal barrier: When the other way round is the only way around!

BACKGROUND: The pseudoaneurysms of the internal carotid artery (ICA) at the skull base form a unique subset of craniofacial pseudoaneurysms with varied diagnostic and therapeutic challenges. Recurrence in a surgically treated pseudoaneurysm may become a nightmare due to very limited number of open and endovascular options. REPORT: We report a rare case of recurrent pseudoaneurysm of petrous ICA, which presented with massive epistaxis following an initial successful occlusion by surgical trapping of the parent arterial segment with surgical clip. Cerebral angiography revealed filling of the pseudoaneurysm by small arterial channels from the external carotid, contralateral internal carotid and basilar arterial branches and emptying through the "slipped" distal clip. After a meticulous analysis of the cerebral angiogram, the recurrent pseudoaneurysm was eventually embolized retrogradely through the "slipped" clip after crossing the anterior communicating artery taking a contralateral internal carotid access. CONCLUSION: Scrupulous planning and execution of ICA pseudoaneurysms is necessary to prevent recurrence. Naturally occuring collateral routes through the Circle of Willis aid in treatment of "unreachable" vascular lesions.