Tricks to do a quick successful bronchial artery embolization (BAE) in massive haemoptysis

Bronchial artery embolization (BAE) is the mainstay treatment for massive haemoptysis. Herein we briefly discuss the tips and tricks of super-selective embolization of bronchial artery using N-butyl-2 cyanoacrylate (NBCA). Based on our experience, this technique produces a better resolution and exhibit high non- recurrence rate in the treatment of massive haemoptysis

Brain cone beam computed tomography image analysis using ResNet50 for collateral circulation classification

Treatment of stroke patients can be effectively carried out with the help of collateral circulation performance. Collateral circulation scoring as it is now used is dependent on visual inspection, which can lead to an inter- and intra-rater discrepancy. In this study, a collateral circulation classification using the ResNet50 was analyzed by using cone beam computed tomography (CBCT) images for the ischemic stroke patient. The remarkable performance of deep learning classification helps neuroradiologists with fast image classification. A pre-trained deep network ResNet50 was applied to extract robust features and learn the structure of CBCT images in their convolutional layers. Next, the classification layer of the ResNet50 was performed into binary classification as “good” and “poor” classes. The images were divided by 80:20 for training and testing. The empirical results support the claim that the application of ResNet50 offers consistent accuracy, sensitivity, and specificity values. The performance value of the classification accuracy was 76.79%. The deep learning approach was employed to unveil how biological image analysis could generate incredibly dependable and repeatable outcomes. The experiments performed on CBCT images evidenced that the proposed ResNet50 using convolutional neural network (CNN) architecture is indeed effective in classifying collateral circulation

Supraclinoid direct carotid-cavernous sinus fistula

Carotid-cavernous fistulas (CCFs) are vascular shunts between the carotid arterial system with direct drainage into the cerebral venous system, mainly to the cavernous sinus. Direct CCF is a well-recognised complication following head trauma. Classically in direct or traumatic CCF, vessel wall tear occurs at the cavernous segment of the internal carotid artery, between the fixed and free segment. Tears at the supraclinoid segment are rare. We report a case of an internal carotid artery supraclinoid segment pseudoaneurysm, with a direct communication with the cavernous sinus, draining into the superior ophthalmic vein

The Spetzler-Martin grading system and management of patients with intracranial Arteriovenous malformation in a tertiary referral hospital

Introduction: An arteriovenous malformation (AVM) is an abnormal collection of blood vessels in which arterial blood flows directly into the draining vein without the normal interposed capillaries. The Spetzler-Martin grading system has been widely accepted worldwide to estimate the pretreatment risks and predict the outcome of patients with intracranial AVM. In Malaysia, we still do not have the baseline data of this grading system. Methods: A total of 33 patients from a tertiary referral hospital diagnosed with intracranial AVM based on neuroimaging findings over a 4-year period were studied. Medical records were traced and neuroimaging findings were analysed. The AVMs were graded according to the Spetzler-Martin grading system and Fisher’s exact test was used to assess statistical difference between the grades of the AVM and management plan for the patients. Results: Four patients were graded as Grade 1, 9 patients as Grade II, 10 patients as Grade III, 6 patients as Grade IV and 4 patients as Grade V. Ten patients were treated conservatively; six patients underwent surgery and embolisation respectively. Four patients underwent radiosurgery and a combination of embolisation while surgery and radiosurgery were given to 5 patients and 2 patients respectively. Statistically significant difference (p=0.016) was found between the Spetzler-Martin grading system and the management of intracranial AVMs. Conclusion: The management decision was not made based on the grading of the AVMs. It is recommended that all AVM patients be routinely graded according to this system prior to treatment. Keywords: Intracranial arteriovenous malformation

Reversible splenial lesion syndrome in neuroleptic malignant syndrome.

Background: Reversible focal lesions in the splenium of the corpus callosum (SCC) or reversible splenial lesion syndrome are rare and little is known about their pathophysiology. Case summary: The authors describe a case of a 65-year-old female who presented with fever, abnormal behaviour and mild hypernatremia. She was on neuropsychiatric treatment for bipolar disorder but denied any history of seizure. After an extensive workout to exclude infection, a clinical diagnosis of neuroleptic malignant syndrome (NMS) was made. Initial magnetic resonance imaging (MRI) of the brain showed a lesion in the SCC characterized by high-signal intensity on T2-weighted and FLAIR sequences with reduced signal intensity on T1-weighted sequence. Diffuse weighted imaging (DWI) showed restricted diffusion. There was no enhancement following Gadolinium administration. The follow-up MRI 8 weeks later showed complete resolution of the SCC lesion. Conclusion: While the pathophysiology of reversible SCC lesions is still unclear, this case highlights the need to consider NMS in the differential diagnosis of reversible splenial lesion of the corpus callosum

Endovascular treatment of cerebral aneurysm: early experience in a Malaysian tertiary centre

Universiti Kebangsaan Malaysia Medical Center (UKMMC) started neurointerventional service in August 2008. In this study, we aimed to evaluate the immediate and short term outcome of endovascular treatment (EVT) of cerebral aneurysm during early period of the services. A retrospective study for cerebral aneurysm treated by endovascular technique, from the Neurosurgical and Radiology Department from September 2008 till February 2010 was performed. Patient's demographic data, initial clinical presentation and assessment of the aneurysm were performed. The immediate results and short term assessment post EVT were evaluated based on standard criteria. Recurrence and complications during and following EVT procedures, were recorded. Twenty one patients with total of 22 aneurysms were treated. The mean age was 54.52 years with 57 being males and 43 females. The majority (81) had single aneurysm. The most common site was anterior communicating artery (28 ). Mean aneurysm sac size was 6.19 mm and 2.55 mm for aneurysm neck. At follow-up, 3 (27.2) had a small residual neck. Four patients (37.2) had residual aneurysm filling, but three of them were treated with stent aiming to achieve flow diversion effect instead of complete occlusion during initial treatment. There was no rebleed or rupture from the immediate to follow-up. Significant complications up to 30-days was observed in 4 patients (20) whereby 2 patients showed improvement and 2 patients died (10 mortality rate). Endovascular treatment of cerebral aneurysms performed in our centre had early outcome, morbidity and mortality compared to other higher volume centres. Longer term follow up is needed to evaluate the long termoutcome/occlusion rate, morbidity and mortality

Tuberculous meningitis: neuroimaging features, clinical staging and outcome

Forty-two patients diagnosed with tuberculous meningitis in Kuala Lumpur Hospital based on clinical criteria, cerebrospinal fluid analysis and response to antituberculous treatment over a seven year period were included in this study. Relevant information was obtained from pa-tients’ medical case notes and neuroimaging findings were evaluated. The clinical presentation of pa-tients was staged according to Medical Research Council for tuberculous meningitis. Fisher’s Exact Test was used to determine the correlation between the neuroimaging features, clinical staging and outcome of patients. 52.4% of patients had stage 2 disease, 28.6% stage 3 and the remainder stage1 disease. 95.2% of patients had various neuroimaging abnormalities and only 4.8% had normalneuroimaging findings. The commonest neuroimaging findings were hydrocephalus and meningealenhancement. 47.6% of patients survived without any complication. 23.8% developed morbidity ei-ther with minor or major neurological deficit and 28.6% had died at the end of the study period.Among patients with negative neuroimaging findings, one died and another one survived withoutany complication. Among patients with abnormal neuroimaging findings, 25% developed morbidity,27.5% died and 47.5% survived without complication. The only neuroimaging feature significantlycorrelated with clinical outcome was the presence of hydrocephalus. Therefore, hydrocephalus isimportant in the prognosis of the disease and should be considered an indicator of poor clinical out-come. There was no significant correlation between clinical staging and clinical outcome, nor wasthere a significant correlation between clinical staging and individual neuroimaging feature

Padimedical: Medical Image Sharing Portal with DICOM Viewer – User Experience

Digital Imaging and Communication in Medicine (DICOM) is a standard medical imaging format for medical imaging information and data. Availability to access DICOM files remotely using smartphones has shown to improve healthcare systems especially for communication between doctors fromdifferent centres. Most of DICOM files need to be viewed using conventional institutional DICOM viewer. We developed software which allows medical personnel to access DICOM images remotely from their smartphone. This newly created software platform is named Padimedical. This pilot study aims to evaluate users’ satisfaction and usability. Practising medical doctors from a radiology department in a tertiary referral centre were chosen as correspondents in this study. The survey form was sent to over 30 doctors via email. A total of 24 out of 30 respondents completed the survey. The survey showed that Padimedical DICOM viewer was easily accessible (100%), compatible with OS operating system (100%), user-friendly (87.1%), and high signal to noise ratio (100%). All respondents (100%) agreed that the image viewing was smooth and responsive. All respondents would recommend to their peers (n=24). A total of 18 respondents suggested that the quality of images was high (76%) and 23 respondents suggested that the contents in this newly created platform were easy to share (96.15%). All the participants were able to make the correct diagnosis using Padimedical. Overall, the rating of our platform is 4.3 out of 5. Conclusion: Based on this pilot survey, Padimedical software was easily accessible remotely using smartphones, compatible with OS operating system, viewing images were smooth and responsive, produce high-quality image, and easy to share DICOM contents.Keywords—DICOM, images, software

Endovascular Treatment of Intracranial Aneurysms: Diversity in Treatment Techniques of Varying Anatomical Presentations

We discuss and illustrate various endovascular treatment options for intracranial aneurysms, to reflect common technique used in endovascular treatment of brain aneurysm. We select five cases of various aneurysm types to show assortments of endovascular treatment (EVT) are performed. Selective catheterization of the intracranial aneurysms and endovascular treatments are technically feasible, offering a viable alternative to the surgical approach. We discuss the radiographic features, clinical presentation, and strategies of endovascular treatment of intracranial aneurysms. Key words: endovascular treatment, intracranial aneurysm, intracranial stent, balloon assisted

Numerical modelling of blood cells distribution in flow through cerebral artery aneurysm

Recent aneurysm studies have focused on the correlation between different parameters and rupture risk; however, there have been conflicting findings. Computational fluid dynamics (CFD) allows for better visualization but idealized aneurysm models may neglect important variables such as aneurysm shape and blood flow conditions. In this paper, one case of an aneurysm was studied with CFD using a non-Newtonian Power Law Model to investigate the correlation between wall shear stress and blood cells distribution. Results show that velocity of blood flow decreased as it entered the aneurysm and the neck of the aneurysm experienced a greater magnitude of wall shear stress than the remainder of the cerebral artery. Besides, the blood cells generally begin at low velocities and increase after the first curve of the artery. Findings and further studies with larger cases of patients will improve treatment and prevention of aneurysm ruptures