Is CT-A Always Reliable in Detecting Active Bleeding in Closed Pelvic Fractures? Management of a Case with Multiple Closed Pelvic Fratures and Internal Iliac Artery Bleeding.

One of the most important complications of pelvic injuries is hemorrhage which can be attributed to the venus plexus of the pelvis, the damaged bone on the fracture site, or in 15% of cases to arterial cause. In the last case mortality could reach 70%. Clinical case presentation, a 77-year-old man, presented in the emergency department of our hospital hemodynamically unstable due to fall from height (3 meters) with comminuted bilateral fractures of the pubic rami, right sacral and iliac wing fracture, right acetabular fracture, fractures of transverse processes of the first, second, and fifth lumbar spine vertebrae and a periprothetic fracture of the right femur. Advanced trauma life support (ATLS) protocol was followed throughout. Computed tomography (CT) scans and CT angiography performed, showed the above mentioned pelvic fractures that did not require stabilization, without further injuries, and a well described retroperitoneal hematoma without any evidence of active bleeding. During the resuscitation process the patient developed cardiac arrest and cardiopulmonary resuscitation (CPR) protocol was followed. The patient was intubated and retained his cardiac rhythm. However, he remained unstable and an angiography was then performed that revealed internal iliac artery bleeding and embolism of the internal iliac artery was performed. The patient was stabilized and was transferred to the intensive care unit for further management. Arterial hemorrhage due to pelvic injury is less common, however presents with high rates of mortality. CT angiography may in some cases not reveal existing active bleeding, misleading the clinician. Therefore, in patients with high clinical suspicion of arterial pelvic hemorrhage who remain unstable during the initial resuscitation and do not present with other primary source of bleeding, an angiography and embolism should be performed as soon as possible.

Endovascular management of spontaneous intracranial pseudoaneurysms in a pediatric patient with Noonan syndrome. A mere coincidence or a possible association with the disorder?

BACKGROUND: Noonan syndrome (NS) is a rare autosomal-dominant neurodevelopmental disorder, which typically develops abnormalities of the craniofacial development and congenital heart defects. A number of cerebrovascular anomalies have also been occasionally described previously in the setting of NS. The assumption that NS can induce the formation of intracranial pseudoaneurysm (IAP) or the rupture of an already existing abnormality is yet unknown. CASE DESCRIPTION: We encountered a rare case of a 9-year-old NS patient with two IAPs presenting with episodes of intracerebral hemorrhage that were successfully managed with endovascular embolization. CONCLUSION: This case represents a possible association between NS and the presence of ruptured IAPs.

Diffusion weighted image documented cerebral ischemia in the postprocedural period following pipeline embolization device with shield technology treatment of unruptured intracranial aneurysms: a prospective, single center study.

OBJECTIVE: Acute ischemic stroke and silent cerebral infarctions following pipeline embolization device (PED) treatment of intracranial aneurysms have been estimated to occur in 3-6% and in 50.9-90% of patients respectively. The PED with Shield technology (PED-Shield) incorporates a surface phosphorylcholine polymer to reduce the thrombogenicity of the implant. We sought to determine the incidence of diffusion weighted image (DWI) documented cerebral ischemia after PED-Shield treatment of unruptured intracranial aneurysms. METHODS: This prospective study involved a single center series of consecutive patients treated for an unruptured intracranial aneurysm with the PED-Shield. All participants underwent clinical evaluation on admission, after the procedure, at discharge, and 30 days following treatment. Brain MRI was obtained within 72 hours of the procedure. Ischemic lesions identified on DWI sequences where examined as to their number, size, and location in relation to the procedure. RESULTS: Over 12 months, 33 patients harboring 38 intracranial aneurysms were treated with the PED-Shield in 36 procedures. Neither mortality nor clinically evident ischemic events were noted in the 30 day postprocedural period. DWI documented, silent cerebral ischemia occurred in six patients (18.18%) after six procedures (16.66%). No statistically significant risk factors for postprocedural silent cerebral ischemia were identified. CONCLUSION: We demonstrated a reduced rate of silent cerebral infarcts following PED-Shield treatment of intracranial aneurysms than previously reported with other endovascular treatment modalities and with the previous device generations. Further research is necessary to evaluate our results and to identify methods to reduce the incidence of postprocedural cerebral ischemic events.