Safety of An Enhanced Recovery After Surgery Protocol After Head and Neck Free Tissue Transfer.

OBJECTIVES: Implementing enhanced recovery after surgery (ERAS) protocols and decreasing length of stay (LOS) have become a priority for major surgeries, including microvascular free tissue transfer (MVFTT) reconstruction of the head and neck. We describe an ERAS protocol with the goal to further reduce length of stay beyond national medians. METHODS: Retrospective chart review between August 2016 and February 2023, including all patients who underwent MVFTT after oral cavity, skull base, salivary gland, and cutaneous ablative surgery. An ERAS protocol was implemented in March 2020. RESULTS: A total of 383 patients were included. Approximately 59.8% underwent oral cavity MVFTT, 34.5% cutaneous and lateral skull base, and 5.8% maxillary and anterior skull base. A total of 209 (54.7%) patients had surgery prior to implementation of the ERAS protocol and 174 (45.3%) after. Median LOS decreased from 9 days (interquartile interval [IQR] 8-11) to 6 (IQR 5-7.5, p < 0.0001) following oral cavity MVFTT. For cutaneous and lateral skull base reconstruction, median LOS decreased from 6 days (IQR 5-8) to 3 (IQR 3-7, p < 0.0001). For anterior skull base and sinonasal MVFTT, median LOS decreased from 8 (IQR 7-9) to 5 days (IQR 4.5-7, p = 0.0005). Rate of discharge to skilled nursing or subacute rehabilitation facilities decreased (24% before ERAS, 9.2% after, p < 0.0001). Thirty-day readmission rate was similar before and after implementation (10.5% vs. 10.3, p = 0.954). Discharge to facility was associated with readmission (OR 2.34, 95% CI 1.12-4.89, p = 0.024). CONCLUSION AND RELEVANCE: Implementation of the ERAS protocol was associated with decreased LOS. There was no increase in rate of readmission. LEVEL OF EVIDENCE: N/A Laryngoscope, 2024.

Comparison of Early Postoperative Step and Stair Counts With the Direct Anterior Approach Versus the Posterior Approach for Total Hip Arthroplasty.

BACKGROUND: The purpose of this study was to evaluate the impact of direct anterior approach (DAA) or posterior approach (PA) on step and stair counts after total hip arthroplasty using a remotely monitored mobile application with a smartwatch while controlling for baseline characteristics. METHODS: This is a secondary data analysis from a prospective cohort study of patients utilizing a smartphone-based care management platform. The primary outcomes were step and stair counts and changes from baseline through one year. Step and stair counts were available for 1,501 and 847 patients, respectively. Longitudinal regression models were created to control for baseline characteristics. RESULTS: Patients in the DAA group had significantly lower body mass index (P = .049) and comorbidities (P = .028), but there were no significant differences in age (P = .225) or sex (P = .315). The DAA patients had a higher average and improvement from baseline in step count at 2 and 3 weeks postoperatively after controlling for patient characteristics (P = .028 and P = .044, respectively). The average stair counts were higher for DAA patients at one month postoperatively (P = .035), but this difference was not significant after controlling for patient demographics. Average stair ascending speeds and changes from baseline were not different between DAA and PA patients. Descending stair speed was higher at 2 weeks postoperatively for DAA patients, but was no longer higher after controlling for baseline demographics. CONCLUSIONS: After controlling for baseline characteristics, DAA patients demonstrate earlier improvement in step count than PA patients after total hip arthroplasty. However, patient selection and surgeon training may continue to influence outcomes through a surgical approach.

Collaborative Development and Implementation of a Hybrid Virtual Surgery Clerkship Curriculum in a Vietnamese Medical School.

OBJECTIVE: To collaboratively develop a hybrid virtual curriculum for a medical school surgery clerkship within an emerging medical university in Vietnam. DESIGN: A hybrid virtual surgery clerkship curriculum was collaboratively developed by Vietnamese and American surgeons as part of an international partnership between their respective universities. A set of 25 virtual lectures with associated materials were created and deployed in tandem with live, in-person review and skills sessions. Student quantitative and qualitative evaluation methods were developed and deployed to allow continuous iteration. A 6-month course was deployed to develop surgical faculty into effective teachers. SETTING: The curriculum was deployed at VinUniversity College of Health Sciences, the youngest medical university in Vietnam. It was developed in collaboration with the University of Pennsylvania Perelman School of Medicine. Each cohort of 12 students in the surgical clerkship will participate in the curriculum. CONCLUSIONS: The development of this hybrid surgical clerkship in Vietnam leveraged local resources and expertise with those available remotely. Lessons learned are directly applicable to future collaborative curriculum development efforts at other emerging medical schools.

Endovascular Applications for the Management of High-Grade Gliomas in the Modern Era.

High-grade gliomas (HGGs) have a poor prognosis and are difficult to treat. This review examines the evolving landscape of endovascular therapies for HGGs. Recent advances in endovascular catheter technology and delivery methods allow for super-selective intra-arterial cerebral infusion (SSIACI) with increasing precision. This treatment modality may offer the ability to deliver anti-tumoral therapies directly to tumor regions while minimizing systemic toxicity. However, challenges persist, including blood-brain barrier (BBB) penetration, hemodynamic complexities, and drug-tumor residence time. Innovative adjunct techniques, such as focused ultrasound (FUS) and hyperosmotic disruption, may facilitate BBB disruption and enhance drug penetration. However, hemodynamic factors that limit drug residence time remain a limitation. Expanding therapeutic options beyond chemotherapy, including radiotherapy and immunobiologics, may motivate future investigations. While preclinical and clinical studies demonstrate moderate efficacy, larger randomized trials are needed to validate the clinical benefits. Additionally, future directions may involve endovascular sampling for peri-tumoral surveillance; changes in drug formulations to prolong residence time; and the exploration of non-pharmaceutical therapies, like radioembolization and photodynamic therapy. Endovascular strategies hold immense potential in reshaping HGG treatment paradigms, offering targeted and minimally invasive approaches. However, overcoming technical challenges and validating clinical efficacy remain paramount for translating these advancements into clinical care.

Healthcare Spending and Systemic Bevacizumab for Recurrent Respiratory Papillomatosis.

OBJECTIVES: Juvenile-onset recurrent respiratory papillomatosis (JoRRP) is a rare, costly condition linked to human papillomavirus. Standard of care is serial surgical debridement. Many adjunctive therapies have been trialed, with recent success with systemic bevacizumab. This paper examines healthcare spending associated with systemic bevacizumab use for JoRRP and compares it to healthcare spending for surgical care alone to determine whether bevacizumab has a financial benefit. METHODS: Five patients treated with systemic bevacizumab for JoRRP were identified at a single institution. Spending data was derived from the electronic medical record. Sensitivity analysis was performed using variation in spending and frequency of treatments. RESULTS: Patients had an average of 4.2 treatments per year prior to bevacizumab (95% confidence interval [CI] 1.4-7.0) and 1.1 after (0.2-2.0). Patients underwent an average of 9.2 bevacizumab treatments in their first year after initiation, 4.0 in the second, and 4.5 in their third. Mean payment per debridement was $3198 ($2856-3539), with mean total surgical payment per year of $17,966 ($11,673-24,259) prior to initiating bevacizumab. Mean payment on a single bevacizumab infusion visit was $6508 ($6063-6952). Mean total surgical and bevacizumab spending per year after bevacizumab initiation were $83,951 ($12,938-154,964). CONCLUSIONS: Accounting for variations in the number of treatments per year with bevacizumab after initiation, healthcare spending after bevacizumab initiation is similar to spending on surgery alone for JoRRP in patients with severe disease.

Management of moyamoya disease: a review of current and future therapeutic strategies.

Moyamoya disease (MMD) is characterized by idiopathic, progressive stenosis of the circle of Willis and the terminal portion of the internal carotid arteries with the development of prominent small collateral vessels and a characteristic moyamoya or puff-of-smoke radiographic appearance. The incidence and prevalence of MMD varies by region, age, and sex, with higher rates in Asian and East Asian populations compared to North American or European populations. There is a bimodal distribution of patients diagnosed with MMD. Pediatric patients are more commonly diagnosed within the 1st decade of life, whereas adult patients present in the 5th or 6th decade of life. Overall, there is a nearly 2:1 female-to-male ratio. Ischemic symptoms are the most common presentation in pediatric and adult populations, but adult patients are nearly twice as likely to present with intracranial hemorrhage compared to their pediatric counterparts. Surgical revascularization is indicated in symptomatic cases, and antiplatelet therapy may be a useful adjunct to prevent recurrent symptoms. Direct and combined bypass procedures seem to be more effective in adults, whereas children respond well to indirect bypass. The identification of key genetic, molecular, and environmental factors including RNF213 and GUCY1A3 loss-of-function mutations, angiogenic growth factors, autoantibodies, CNS infections, and radiation exposure suggest multiple pathways for the development of moyamoya arteriopathy. Further research is needed to better understand the heterogeneity of pathogenetic mechanisms that lead to moyamoya and to identify novel therapeutic targets to prevent, stabilize, and treat MMD.

Evaluating The Role of ChatGPT as a Study Aid in Medical Education in Surgery.

OBJECTIVE: Our aim was to assess how ChatGPT compares to Google search in assisting medical students during their surgery clerkships. DESIGN: We conducted a crossover study where participants were asked to complete 2 standardized assessments on different general surgery topics before and after they used either Google search or ChatGPT. SETTING: The study was conducted at the Perelman School of Medicine at the University of Pennsylvania (PSOM) in Philadelphia, Pennsylvania. PARTICIPANTS: 19 third-year medical students participated in our study. RESULTS: The baseline (preintervention) performance of participants on both quizzes did not differ between the Google search and ChatGPT groups (p = 0.728). Students overall performed better postintervention and the difference in test scores was statistically significant for both the Google group (p < 0.001) and the ChatGPT group (p = 0.01). The mean percent increase in test scores pre- and postintervention was higher in the Google group at 11% vs. 10% in the ChatGPT group, but this difference was not statistically significant (p = 0.87). Similarly, there was no statistically significant difference in postintervention scores on both assessments between the 2 groups (p = 0.508). Postassessment surveys revealed that all students (100%) have known about ChatGPT before, and 47% have previously used it for various purposes. On a scale of 1 to 10 with 1 being the lowest and 10 being the highest, the feasibility of ChatGPT and its usefulness in finding answers were rated as 8.4 and 6.6 on average, respectively. When asked to rate the likelihood of using ChatGPT in their surgery rotation, the answers ranged between 1 and 3 ("Unlikely" 47%), 4 to 6 ("intermediate" 26%), and 7 to 10 ("likely" 26%). CONCLUSION: Our results show that even though ChatGPT was comparable to Google search in finding answers pertaining to surgery questions, many students were reluctant to use ChatGPT for learning purposes during their surgery clerkship.

Randomized Clinical Trials in Cerebrovascular Neurosurgery From 2018 to 2022.

There has been an exponential increase in randomized controlled trials (RCTs) on cerebrovascular disease within neurosurgery. The goal of this study was to review, outline the scope, and summarize all phase 2b and phase 3 RCTs impacting cerebrovascular neurosurgery practice since 2018. We searched PubMed, MEDLINE, Embase, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials (CENTRAL) databases for relevant RCTs published between January 1, 2018, and July 1, 2022. We searched for studies related to eight major cerebrovascular disorders relevant to neurosurgery, including acute ischemic stroke, cerebral aneurysms and subarachnoid hemorrhage, intracerebral hemorrhage, subdural hematomas, cerebral venous thrombosis, arteriovenous malformations, Moyamoya disease and extracranial-intracranial bypass, and carotid and intracranial atherosclerosis. We limited our search to phase 2b or 3 RCTs related to cerebrovascular disorders published during the study period. The titles and abstracts of all relevant studies meeting our search criteria were included. Pediatric studies, stroke studies related to rehabilitation or cardiovascular disease, study protocols without published results, prospective cohort studies, registry studies, cluster randomized trials, and nonrandomized pivotal trials were excluded.  From an initial total of 2,797 records retrieved from the database searches, 1,641 records were screened after duplicates and studies outside of our time period were removed. After screening, 511 available reports within our time period of interest were assessed for eligibility. Pediatric studies, stroke studies related to rehabilitation or cardiovascular disease, study protocols without published results, prospective cohort studies, registry studies, cluster randomized trials, and nonrandomized pivotal trials were excluded. We found 80 unique phase 2b or 3 RCTs that fit our criteria, with 165 topic-relevant articles published within the study period.  Numerous RCTs in cerebrovascular neurosurgery have been published since 2018. Ischemic stroke, including mechanical thrombectomy and thrombolysis, accounted for a majority of publications, but there were large trials in intracerebral hemorrhage, subdural hemorrhage, aneurysms, subarachnoid hemorrhage, and cerebral venous thrombosis, among others. This review helps define the scope of the large RCTs published in the last four years to guide future research and clinical care.

Immediate plate fixation of open tibial plafond fractures does not elevate risk of infection.

OBJECTIVE: To determine if immediate plate fixation of open tibial plafond fractures has a negative effect on soft tissue complications and increases the risk of deep infection. DESIGN: This was a single-institution retrospective cohort study performed at level-1 trauma center. All patients with open OTA/AO 43C plafond fractures treated over 20-year period with follow-up until fracture union or development of deep infection. Ninety-nine of 333 identified patents met the inclusion criteria. The intervention was operative treatment of open tibial plafond fractures. The main outcome measurements were return to operating room for deep infection, nonunion, and below knee amputation. RESULTS: The overall rate of complications was 52%. Gender, body mass index, tobacco use, diabetes, ASA classification, time to OR from injury, wound location, and associated fibula fracture were not associated with deep infection. There was a significant difference in Gustilo-Anderson fracture grade among infected versus non-infected (P = 0.04). There was no significant difference in postoperative infection rates between patients treated with external fixation, external fixation and limited plate fixation, and plate fixation alone during initial surgery (P = 0.64). CONCLUSION: It is well established that open pilon fractures have a high incidence for postoperative infection and development of complications such as nonunion. As these injuries have poor clinical outcomes, any additional measures to prevent infection and soft tissue complications should be utilized. In appropriately selected cases, both immediate plate fixation and immediate limited plate fixation with external fixation at the time of I&D do not appear to elevate risk of deep infection. LEVEL OF EVIDENCE: Therapeutic Level III.

Strategies for Implementing Machine Learning Algorithms in the Clinical Practice of Radiology.

Despite recent advancements in machine learning (ML) applications in health care, there have been few benefits and improvements to clinical medicine in the hospital setting. To facilitate clinical adaptation of methods in ML, this review proposes a standardized framework for the step-by-step implementation of artificial intelligence into the clinical practice of radiology that focuses on three key components: problem identification, stakeholder alignment, and pipeline integration. A review of the recent literature and empirical evidence in radiologic imaging applications justifies this approach and offers a discussion on structuring implementation efforts to help other hospital practices leverage ML to improve patient care. Clinical trial registration no. 04242667 © RSNA, 2024 Supplemental material is available for this article.

Medical Student Perceptions of Academic Surgery: Rose-Colored Glasses or Jaded Prism?

OBJECTIVE: Stereotypes of surgeons are pervasive and play a role in medical students' decisions about pursuing a surgical career. This study aimed to determine: (1) how medical students' perceptions of surgery and surgeons changed following exposure to surgery during clerkship rotations; and (2) if gender and racial/ethnic identification played a role in this process. DESIGN, SETTING, AND PARTICIPANTS: In this mixed-method study, clerkship students at one U.S. medical school were asked to anonymously contribute words and phrases that they associated with surgery to an online "word cloud" at the beginning and end of their 12-week surgery clerkship. In addition, an end-of-year, anonymous survey of their perceptions was administered and analyzed using a Grounded Theory approach. RESULTS: Of 154 students invited to complete the online survey, analysis of 24 completed surveys suggested that students believe surgical culture to be toxic, with unfriendly attitudes, strict hierarchy, and lack of work-life balance. Analysis of 678 Word Cloud responses, however, indicated that the frequency of complimentary responses increased following surgery clerkships (25% vs 36%; z = -3.26; p = 0.001), while the proportion of responses describing surgery/surgeons as male-dominated, egotistical, and scary decreased (5% vs 1%, z = 2.86, p = 0.004; 9% vs 4%, z = 2.78, p = 0.005; 3% vs 0.3%, z = 2.56, p = 0.011, respectively). The association between surgeons and being White disappeared entirely. Female students were more likely than male students to state that their perceptions did not change following exposure (40% vs 0%; z = 2.19; p = 0.029). CONCLUSIONS: With exposure to surgery, students' preconceived notions may be positively influenced. However, students continue to hold negative perceptions, and this effect may be stratified by gender identification. Institutions should work to address these perceptions in pre-clerkship years to attract a more diverse pool of future surgeons.

Posterior cerebral territory ischemia in pediatric moyamoya: Surgical techniques and long-term clinical and radiographic outcomes.

PURPOSE: To describe a surgical technique for posterior cerebral revascularization in pediatric patients with moyamoya arteriopathy. Here, we describe the clinical characteristics, surgical indications, operative techniques, and clinical and radiographic outcomes in a series of pediatric patients with moyamoya disease affecting the posterior cerebral artery (PCA) territory. METHODS: A retrospective single-center series of all pediatric patients with moyamoya disease who presented to our institute between July 2009 through August 2019 were reviewed. The clinical characteristics, surgical indications, operative techniques, and long-term clinical and radiographic outcomes of pediatric moyamoya patients with PCA territory ischemia were collected and analyzed. RESULTS: A total of 10 PCA revascularization procedures were performed in 9 patients, 5 female, ages 1 to 11.1 years (average 5.2 years). Complications included 1 stroke, with no infections, hemorrhages, seizures, or deaths. One patient had less than 1 year of radiographic and clinical follow-up. In 8 of 9 patients with at least 1 year of radiographic follow-up, there was engraftment of surgical vessels present in all cases. No new strokes were identified on long-term follow-up despite the radiographic progression of the disease. In the 8 cases available for analysis, the average follow-up was 50.8 months with a range of 12 to 117 months. CONCLUSIONS: PCA territory ischemia in patients with progressive moyamoya disease can be surgically treated with indirect revascularization. Here, we describe our experience with PCA revascularization procedures for moyamoya disease, including pial pericranial dural (PiPeD) revascularization and pial synangiosis utilizing the occipital artery. These surgical options may be useful for decreasing the risk of stroke in pediatric moyamoya patients with severe posterior circulation disease.

Prevention of postoperative stroke in pediatric moyamoya patients: a standardized perioperative care protocol.

OBJECTIVE: Perioperative stroke is a major complication of revascularization surgery in patients with moyamoya. Vomiting is common after neurosurgical procedures and may result in acute changes in intracranial pressure and cerebral blood flow. The authors instituted a standardized perioperative nausea and vomiting protocol for children with moyamoya undergoing indirect bypass surgery at their institution and analyzed its association with perioperative stroke. They hypothesized that instituting a standardized perioperative nausea and vomiting protocol would be associated with reduction in the number of perioperative strokes in children with moyamoya undergoing indirect bypass surgery. METHODS: The authors retrospectively reviewed consecutive cases of children and young adults with moyamoya who underwent indirect bypass surgery before and after implementation of a new perioperative nausea and vomiting protocol at a single institution. They compared the rate of strokes in the perioperative period (postoperative days 0 and 1) in the 31 months following implementation to 31 months prior to implementation using Fisher's exact test. RESULTS: The median ages pre- and postimplementation were 8.5 (IQR 4-12) years and 8.3 (IQR 5-15) years, respectively. There were no significant differences between the cohorts in disease severity or other potentially confounding factors. In the 31 months prior to initiation of the perioperative nausea and vomiting protocol, there were 5 strokes in 137 surgically treated hemispheres (3.6%). After initiation of the protocol, there were no strokes in 114 surgically treated hemispheres (p = 0.065). CONCLUSIONS: Instituting a standardized perioperative nausea and vomiting protocol was associated with reduction in perioperative strokes in children with moyamoya treated with indirect bypass surgery.

Combination endovascular and microsurgical treatment of partially thrombosed ruptured ICA terminus aneurysm, with common carotid artery to MCA bypass via saphenous vein graft and parent vessel sacrifice after coil embolization.

A 63-year-old woman presented with ruptured giant ICA terminus aneurysm, temporized with coil embolization and definitively treated with parent vessel sacrifice and high-flow bypass.

Craniocervical dural arteriovenous fistula: Microsurgical clipping and technical nuances with ICG.

A 48-year-old male with progressive congestive myelopathy had a craniocvervical DAVF treated with surgical clipping using ICG to confirm solitary inflow.

Cavernous venous malformations in and around the central nervous system. Part 1: Dural and extradural.

Cavernous-type malformations are venous lesions that occur in multiple locations throughout the body, and when present in the CNS, they have canonically been referred to as cavernomas, cavernous angiomas, and cerebral cavernous malformations. Herein all these lesions are referred to as "cavernous venous malformations" (CavVMs), which is congruent with the current International Society for the Study of Vascular Anomalies classification system. Even though histologically similar, depending on their location relative to the dura mater, these malformations can have different features. In Part 1 of this review, the authors discuss and review pertinent clinical knowledge with regard to CavVMs as influenced by anatomical location, starting with the dural and extradural malformations. They particularly emphasize dural CavVMs (including those in the cavernous sinus), orbital CavVMs, and spinal CavVMs. The genetic and histopathological features of CavVMs in these locations are reviewed, and commonalities in their presumed mechanisms of pathogenesis support the authors' conceptualization of a spectrum of a single disease entity. Illustrative cases for each subtype are presented, and the pathophysiological and genetic features linking dural and extradural to intradural CavVMs are examined. A new classification is proposed to segregate CavVMs based on the location from which they arise, which guides their natural history and treatment.

Cavernous venous malformations in and around the central nervous system. Part 2: Intradural.

Cavernous venous malformations (CavVMs) account for a spectrum of lesions with a shared pathogenesis. Their anatomical location dictates their clinical features and surgical treatment. Extradural and dura-based CavVMs were discussed in Part 1 of this review. In this part, intradural CavVMs are discussed, encompassing malformations growing within the intradural space without direct dural involvement. In addition to classic intra-axial CavVMs, cranial nerve CavVMs, intraventricular CavVMs, and intradural extramedullary spinal CavVMs are discussed in this group, given the similar natural history and specific management challenges. Herein the authors focus on critical clinical aspects of and surgical management of these malformations based on their location and discuss optimal surgical approaches at each of these anatomical locations with illustrative cases. The commonalities of the natural history and surgical management that are dictated by anatomical considerations lend to a new location-based taxonomy for classification of CavVMs.

Brain AVM surgery without endovascular embolization in a low to middle income country.

We treated a 20-year-old woman in Paraguay with a ruptured intraventricular Spetzler-Martin Grade 3 AVM, and illustrate microsurgical resection without embolization in this video.

Type 1 Thyroplasty for Chronic Cough.

OBJECTIVES: Type 1 thyroplasty is a vital component of treatment for vocal fold hypomobility, immobility, and atrophy. However, patients with other laryngeal symptoms, including chronic cough, can have concomitant vocal fold atrophy and glottic insufficiency on the exam. Previous work has demonstrated that injection laryngoplasty can assist with treating cough in patients with glottic insufficiency. However, the role of type 1 thyroplasty for cough has not been well described. METHODS: Case series of five patients treated by a fellowship-trained laryngologist at a tertiary voice center. RESULTS: Five patients underwent type 1 thyroplasty for chronic cough. All five patients had a chronic cough that was not responsive to medical management. One patient underwent a previous superior laryngeal nerve block, which was effective for three weeks. Prior to surgery, all patients had a trial injection laryngoplasty with temporary improvement in symptoms. Four of five patients underwent bilateral GoreTex type 1 thyroplasty; one underwent only unilateral thyroplasty due to subtle vocal fold hypomobility on that side. All patients had improvement in their cough, with follow-up periods ranging from one month to three years. CONCLUSION: There are limited therapeutic options for chronic cough refractory to medical therapy. For patients with vocal fold atrophy or glottic insufficiency, type 1 thyroplasty may offer a durable option to improve cough.

Recurrent Intraventricular Haemorrhage in Cerebral Proliferative Angiopathy - A Case Report and Review of the Literature.

Cerebral proliferative angiopathy (CPA) is an entity distinct from that of classical arteriovenous malformations. As such, few reports have considered the long-term follow-up of patients with hemorrhage in CPA. Accordingly, herein the authors present a case of recurrent hemorrhage in CPA with 32 years of follow-up and in so doing summarize the literature of hemorrhagic cases in CPA. A 19-year-old presented with focal awareness seizures and diagnostic work-up revealed a left hemispheric vascular lesion. The patient presented again with intracranial hemorrhage at ages 28, 43 and 51. Angioarchitectural workup revealed intermingled brain parenchyma between vascular spaces, absence of dominant feeders and a clear nidus consistent with CPA. The size and diffuse nature of the lesion deemed it inoperable. Given our case and review of the literature it is apparent that CPA has a high risk of re-hemorrhage in the rare event that hemorrhage does occur.