Guidelines for management of actual or suspected inadvertent intra-arterial injection of sclerosants.

BACKGROUND: Inadvertent intra-arterial injection of sclerosants is an uncommon adverse event of both ultrasound-guided and direct vision sclerotherapy. This complication can result in significant tissue or limb loss and significant long-term morbidity. OBJECTIVES: To provide recommendations for diagnosis and immediate management of an unintentional intra-arterial injection of sclerosing agents. METHODS: An international and multidisciplinary expert panel representing the endorsing societies and relevant specialities reviewed the published biomedical, scientific and legal literature and developed the consensus-based recommendations. RESULTS: Actual and suspected cases of an intra-arterial sclerosant injection should be immediately transferred to a facility with a vascular/interventional unit. Digital Subtraction Angiography (DSA) is the key investigation to confirm the diagnosis and help select the appropriate intra-arterial therapy for tissue ischaemia. Emergency endovascular intervention will be required to manage the risk of major limb ischaemia. This includes intra-arterial administration of vasodilators to reduce vasospasm, and anticoagulants and thrombolytic agents to mitigate thrombosis. Mechanical thrombectomy, other endovascular interventions and even open surgery may be required. Lumbar sympathetic block may be considered but has a high risk of bleeding. Systemic anti-inflammatory agents, anticoagulants, and platelet inhibitors and modifiers would complement the intra-arterial endovascular procedures. For risk of minor ischaemia, systemic oral anti-inflammatory agents, anticoagulants, vasodilators and antiplatelet treatments are recommended. CONCLUSION: Inadvertent intra-arterial injection is an adverse event of both ultrasound-guided and direct vision sclerotherapy. Medical practitioners performing sclerotherapy must ensure completion of a course of formal training (specialty or subspecialty training, or equivalent recognition) in the management of venous and lymphatic disorders (phlebology), and be personally proficient in the use of duplex ultrasound in vascular (both arterial and venous) applications, to diagnose and provide image guidance to venous procedure. Expertise in diagnosis and immediate management of an intra-arterial injection is essential for all practitioners performing sclerotherapy.

Precision Delivery of Human Bone Marrow-Derived Mesenchymal Stem Cells Into the Pancreas Via Intra-arterial Injection Prevents the Onset of Diabetes.

Mesenchymal stem cells (MSCs) are a promising therapy to potentially treat diabetes given their potent anti-inflammatory and immune-modulatory properties. While these regenerative cells have shown considerable promise in cell culture, their clinical translation has been challenging. In part, this can be attributed to these cells not reaching the pancreas to exert their regenerative effects following conventional intravenous (IV) injection, with the majority of cells being trapped in the lungs in the pulmonary first-pass effect. In the present study, we will therefore examine whether direct delivery of MSCs to the pancreas via an intra-arterial (IA) injection can improve their therapeutic efficacy. Using a mouse model, in which repetitive low doses of STZ induced a gentle, but progressive, hyperglycemia, we tested bone marrow-derived MSCs (BM-MSCs) which we have shown are enriched with pro-angiogenic and immunomodulatory factors. In cell culture studies, BM-MSCs were shown to preserve islet viability and function following exposure to proinflammatory cytokines (IFN-γ, IL-1ß, and TNF-α) through an increase in pAkt. When tested in our animal model, mice receiving IV BM-MSCs were not able to mitigate the effects of STZ, however those which received the same dose and batch of cells via IA injection were able to maintain basal and dynamic glycemic control, to similar levels as seen in healthy control animals, over 10 days. This study shows the importance of considering precision delivery approaches to ensure cell-based therapies reach their intended targets to enable them to exert their therapeutic effects.

Enhancing brain entry and therapeutic activity of chimeric antigen receptor T cells with intra-arterial NEO100 in a mouse model of CNS lymphoma.

OBJECTIVE: Malignancies of the CNS are difficult to treat because the blood-brain barrier (BBB) prevents most therapeutics from reaching the intracranial lesions at sufficiently high concentrations. This also applies to chimeric antigen receptor (CAR) T cells, for which systemic delivery is inferior to direct intratumoral or intraventricular injection of the cells. The authors previously reported on a novel approach to safely and reversibly open the BBB of mice by applying intra-arterial (IA) injections of NEO100, a pharmaceutical-grade version of the natural monoterpene perillyl alcohol. The authors hypothesized that this method would enable enhanced brain entry and therapeutic activity of intravenously delivered CAR T cells, which the authors tested in a mouse model of CNS lymphoma. METHODS: Human Raji lymphoma cells were implanted into the brains of immune-deficient mice. After tumor uptake was confirmed with bioluminescent imaging, 0.3% NEO100 was injected intra-arterially, which was followed by intravenous (IV) delivery of CD19-targeted CAR T cells. After this single intervention, tumor growth was monitored with imaging, long-term survival of mice was recorded, and select mice were euthanized to analyze the distribution of CAR T cells in brain tissue. RESULTS: Intravenously injected CAR T cells could be readily detected in brain tumor areas after IA injection of NEO100 but not after IA injection of the vehicle (without NEO100). Although all untreated control animals died within 3 weeks, all mice that received IA NEO100 followed by IV CAR T cells survived and thrived for 200 days, when the experiment was terminated. Of the mice that received IV CAR T cells without prior IA NEO100, 3 died within 3 weeks and 2 survived long-term. CONCLUSIONS: BBB opening by IA NEO100 facilitates brain entry of intravenously delivered CD19 CAR T cells. The long-term survival of all mice with CNS lymphoma, along with the disappearance of the tumor as determined with imaging, suggests that this one-time therapeutic intervention was curative. BBB opening by IA NEO100 may offer a novel option to increase brain access by CAR T cells.

Intra-Arterial Injection of Temporary Embolic Material Through a Needle Inserted into the Radial or Ulnar Artery for Distal and Proximal Interphalangeal Joint Osteoarthritis: A Retrospective Study of 92 Patients.

PURPOSE: To assess the efficacy and safety of intra-arterial injection of imipenem/cilastatin sodium (IPM/CS) via a needle placed into the radial artery or ulnar artery (RA/UA) for distal interphalangeal and proximal interphalangeal joint osteoarthritis (DIP/PIP-OA). MATERIALS AND METHODS: This is a retrospective single-arm cohort study. Ninety-two patients [92% women, mean (SD) age 55(8.3) years] with a primary DIP/PIP-OA meet the American College of Rheumatology criteria for hand osteoarthritis with pain ≥ 4 on the 0-10 numeric rating scale (NRS) were enrolled. All procedures were performed by injecting IPM/CS through a 24-gauge needle percutaneously inserted into the RA/UA. Two procedures were planned; the second procedure was scheduled 1-2 months after the first. NRS, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, Patient Global Impression of Change (PGIC) scale, and procedure-related adverse events were evaluated. RESULTS: Technical success, defined as injection of IPM/CS into the RA/UA, was achieved in all patients. Clinical success, defined as a reduction of 2 points or more in the NRS at 12 months, was 77% (95% confidence interval 68-85%). The NRS improved from the baseline to 3, 6, and 12 months (7.8 ± 1.6 vs. 3.8 ± 2.6, 3.9 ± 2.7, and 4.0 ± 2.8, respectively, all p < 0.001). The QuickDASH score improved from the baseline to 12 months (27 ± 15 vs. 19 ± 17, p < 0.001) respectively. No major adverse events were observed. CONCLUSIONS: Intra-arterial injection of IPM/CS is a feasible treatment option for DIP/PIP-OA.

Contrast administration via ultrasound-guided injection of the cranial tibial artery results in contrast enhancement of the soft tissues of the metatarsus in horses undergoing CT.

Delivery of mesenchymal stem cells (MSC) via intravascular techniques to treat diffuse and/or inaccessible soft tissue injuries has grown in popularity. The purpose of the current prospective, analytical pilot study was to utilize CT to validate this novel technique and provide additional evidence to support its use for injectate delivery to specific soft tissue structures. Of particular interest was the proximal suspensory ligament, which presents a challenging injection target. Six adult horses without lameness underwent CT of the distal hindlimbs. Scans were obtained prior to ultrasound-guided catheterization of the cranial tibial artery, in addition to early and delayed scans acquired following intra-arterial contrast administration. Region of interest analysis of the superficial and deep digital flexor tendons and suspensory ligament was used to assess contrast enhancement within these structures. Linear mixed models were used to determine statistical significance. Significant (P < 0.05) mean contrast enhancement was seen in all postinjection time points in all soft tissue structures of interest. This indicates that ultrasound-guided injection of the cranial tibial artery results in perfusion of injectate throughout the distal hind limb, including the major soft tissue structures of the metatarsus. This provides further support for this technique as a method of MSC delivery to multifocal or inaccessible injury of these structures, including the proximal suspensory ligament.

An experimental study of the vascular embolism caused by recombinant type III collagen implants and hyaluronic acid.

BACKGROUND: There are significant differences in the reported incidence of vascular complications that result from the injection of different soft tissue fillers. This study aimed to compare the risk of vascular embolism after recombinant type III collagen implants and hyaluronic acid (HA) injection into arteries. METHODS: Different concentrations of recombinant type III collagen and Restylane were injected into the central ear artery of rabbits, to construct an immediate embolization model. We screened for vascular recanalization and tissue necrosis at 30 min, 1 day, and 7 days after injection, and histopathology examination was processed on Day 7. RESULTS: At 30 min after injection, complete recanalization of the central ear artery was observed in 17 rabbits in the C1 group while none in the HA group. On Day 1 after injection, complete recanalization of the CEA main trunk was observed in all rabbits in the collagen group while 50% in the HA group. There was a significant difference between the C1 group and the HA group in terms of vascular recanalization and skin necrosis. CONCLUSION: Under the present experimental conditions, the risk of causing vascular embolism was much lower with collagen than with Restylane. Different doses of collagen at different injection rates have the same safety profile.

Targeted Therapy for Glomerulonephritis Using Arterial Delivery of Encapsulated Etanercept.

Complex immunosuppressive therapy is prescribed in medical practice to patients with glomerulonephritis to help them overcome symptoms and prevent chronic renal failure. Such an approach requires long-term systemic administration of strong medications, which causes severe side effects. This work shows the efficiency of polymer capsule accumulation (2.8 ± 0.4 µm) containing labeled etanercept (100 µg per dose) in the kidneys of mice. The comparison of injection into the renal artery and tail vein shows the significant superiority of the intra-arterial administration strategy. The etanercept retention rate of 18% and 8% ID in kidneys was found 1 min and 1 h after injection, respectively. The capsules were predominantly localized in the glomeruli after injection in mice using a model of acute glomerulonephritis. Histological analysis confirmed a significant therapeutic effect only in animals with intra-arterial administration of microcapsules with etanercept. The proposed strategy combines endovascular surgery and the use of polymer microcapsules containing a high molecular weight drug that can be successfully applied to treat a wide range of kidney diseases associated with glomerular pathology.

Intra-arterial injection of Diclofenac by informal health practitioner: A rare complication of a common drug.

Introduction and importance: Intra-arterial injections (IA) though rare, cause acute limb ischaemia with often catastrophic outcomes. Symptoms could progress rapidly and early identification and intervention could help in preventing the limb gangrene. Methodology: The work has been reported in line with the SCARE 2020 criteria:Agha RA, Franchi T, Sohrabi C, Mathew G, for the SCARE Group. The SCARE 2020 Guideline: Updating Consensus Surgical CAse REport (SCARE) Guidelines, International Journal of Surgery 2020; 84:226-230. Operative procedure was performed by consultant of general surgery. Case presentation: 38-year-old male presented to surgery casualty with history of sudden onset of pain and paraesthesia in the left forearm and palm followed by progressive weakness and discolouration, 15 hours following injection of Diclofenac in the mid cubital region. Clinical discussion: On examination, limb temperature was lower, finger movements were minimal. However, distal pulses were palpable, and duplex ultrasound showed normal triphasic flow. In view of the equivocal clinico-radiological findings, the patient underwent CT-Angiography of upper limb, which showed non-opacification of radial and ulnar arteries. Fasciotomy of forearm, brachial artery exploration and removal of embolus was attempted in a doubtful viable left upper limb. No thrombus was noted. Subsequently, he was managed conservatively, and cervical sympathectomy was done. As there was progressive deterioration in the viability of the limb, the patient underwent an above elbow amputation. Conclusion: Intra-arterial injections can lead to limb threatening gangrene, the course of which can be rapid A multidisciplinary team approach was necessary to arrive at a diagnosis and provide optimum care.

Technique of Wide-Awake Local Anesthesia No Tourniquet Injection for a Transradial Forearm Amputation in an Ischemic Hand.

A 48-year-old man with drug addiction presented with gangrene of the right hand following an inadvertent intra-arterial administration of crushed dihydrocodeine tartrate (DF 118) tablets (GlaxoSmithKline S.A.) dissolved in water; the solution was injected into his right antecubital fossa. After 3 weeks of pain, paresthesia, and cyanosis, his right hand became gangrenous. We performed a right forearm amputation by use of the wide-awake local anesthesia no tourniquet technique. After surgery, his wound healed well, and he was successfully fitted with a hand prosthesis.

Method of intra-arterial drug administration in a rat: Sex based optimization of infusion rate.

BACKGROUND: Endovascular thrombectomy is the process of removing a blood clot and re-establishing blood flow in patients with emergent large vessel occlusion. The technique provides an opportunity to deliver therapeutics directly to the site of injury. The intra-arterial (IA) route of drug administration in the mouse was developed to bridge the gap between animal stroke treatments and clinical stroke therapy. Here, we adapted the IA method for use in rats, by investigating various flow rates to optimize the IA injection through the internal carotid artery (ICA). METHODS: Male and female Sprague-Dawley rats (∼4 months of age) were subjected to placement of micro-angio tubing at the bifurcation of the common carotid artery for injection into the ICA. We evaluated a range of infusion rates of carbon black ink and its vascular distribution within the brain. RESULTS: Optimal injection rates in males was 4-6 µl/min and 2-4 µl/min in females. The IA injection using these sex-specific rates resulted in appropriate limited dye delivery to only the ipsilateral region of the brain, without inducing a subarachnoid hemorrhage. CONCLUSION: Upon adapting the IA administration model to rats, it was determined that the rate of infusion varied between males and females. This variability is an important consideration for studies utilizing both sexes, such as in ischemic stroke studies.

Catheter-based Arterial Input Function Determination for Myocardial Perfusion Measurements.

The quantification of myocardial perfusion with contrast agent (CA) tracers requires the precise knowledge of the arterial input function (AIF). In this study a method for MR-guided vascular interventions is evaluated that determines the AIF via an active tracking catheter during targeted CA injection. A phantom experiment with a dialysis filter was conducted to measure the AIF using an active catheter and a dynamic image series as reference. To compensate for dilution and coil sensitivity effects, correction methods were developed for the catheter-based AIF determination. From the dynamic MR measurements in the perfusion phantom quantitative perfusion maps were calculated by a deconvolution of the measured CA concentration with the AIF, and additional flow measurements were used to normalize the perfusion map. The signal-time-curves of the measured AIF using the catheter-based and imaging-based methods agree while the absolute values differ by a scaling factor of about 9. After normalization to the surrounding flow, both perfusion techniques are in excellent agreement. Catheter-based AIF measurements are feasible but require an additional normalization which can be determined from a flow measurement. The technique might enable faster perfusion measurements during cardiovascular interventions.

Feasibility and Efficacy of Intra-Arterial Administration of Embryonic Stem Cell Derived-Mesenchymal Stem Cells in Animal Model of Alzheimer's Disease.

Mesenchymal stem cells (MSCs) promote functional recoveries in pathological experimental models of the central nervous system and are currently being tested in clinical trials for neurological disorders. However, no studies have examined the various roles of embryonic stem cell derived (ES)-MSCs in eliciting therapeutic effects for Alzheimer's disease (AD). In the present study, we investigated the neuroprotective effect of ES-MSCs in cellular and animal models of AD, as well as the safety of the intra-arterial administration of ES-MSCs in an AD animal model. ES-MSCs displayed higher cell viability than that of bone marrow (BM)-MSCs in amyloid-ß (Aß)-induced cellular models. Moreover, the efficacy of autophagy induction in ES-MSCs was comparable to that of BM-MSCs; however, intracellular Aß levels were more significantly reduced in ES-MSCs than in BM-MSCs. In a rat model of AD, ES-MSCs significantly inhibited Aß-induced cell death in the hippocampus and promoted autophagolysosomal clearance of Aß, which was concomitantly followed by decreased levels of Aß in the hippocampus. Furthermore, ES-MSC treatment in Aß-treated rats featured a higher memory performance than that of rats injected solely with Aß. Finally, intra-arterial administration of an appropriate cell density of ES-MSCs was safe and free from in situ occlusion or cerebral ischemia. These data support the therapeutic potential of ES-MSCs and clinical applications of the intra-arterial route of ES-MSC administration in AD.

Single-dose toxicity study by intra-arterial injection of 10BSH entrapped water-in-oil-in-water emulsion for boron neutron capture therapy to hepatocellular carcinoma.

We developed a mixing medical device by attaching Shirasu porous glass Millipore membrane to prepare water-in-oil-in-water (WOW) emulsion in a shorter time to be applied as 10B-entrapped WOW emulsion for hepatocellular carcinoma (HCC) treatment. Single-dose toxicity studies by intra-arterial injection of 10BSH-entrapped WOW were performed in rabbits and pig, and no side effects were observed. We hope to proceed to the preclinical and clinical studies for further evaluation of 10B compound as multidisciplinary treatments for HCC.

Efficacy of intra-arterial indocyanine green angiography for the microsurgical treatment of dural arteriovenous fistula: A case report.

BACKGROUND: In this study, we report a case of dural arteriovenous fistula (dAVF) that was successfully treated using intra-arterial indocyanine green (IA-ICG) videoangiography during open surgery. Moreover, the findings of IA-ICG videoangiography were compared with those of intraoperative digital subtraction angiography (DSA). CASE DESCRIPTION: A 72-year-old male patient with a history of hypertension, hyperlipidemia, and thrombocytosis presented with generalized seizure. DSA revealed Cognard Type III dAVF in the superior wall of the left transverse sinus, which was fed by a single artery (the left occipital artery [OA]) and drained into a single vein (the left temporal cortical vein), without drainage into a venous sinus. Since transarterial embolization was considered challenging due to the tortuosity of the left OA, surgical interruption of the shunt was performed by craniotomy. After excising the feeding artery, we were unable to observed dAVF on intraoperative DSA. However, IA-ICG videoangiography revealed the remaining shunt, which was fed by the collateral route from the feeding artery. The shunting point and draining vein were then surgically resected to eliminate the shunt. The shunt was not observed during the second IA-ICG videoangiography conducted after resection. CONCLUSION: ICG videoangiography is a better method compared with DSA in terms of visualizing fine vascular lesions. In contrast to the typical intravenous administration, selective IA-ICG can be repeatedly injected at a minimal dose. IA-ICG is a useful intraoperative tool that can be used to evaluate the elimination of the dAVF.

Managing intravascular complications following treatment with calcium hydroxylapatite: An expert consensus.

BACKGROUND: Inadvertent intra-arterial injection of dermal fillers including calcium hydroxylapatite (CaHA) can result in serious adverse events including soft tissue necrosis, permanent scarring, visual impairment, and blindness. When intra-arterial injection occurs, immediate action is required for optimal outcomes, but the infrequency of this event means that many physicians may never have experienced this scenario. The aim of this document is to provide evidence-based and expert opinion recommendations for the recognition and management of vascular compromise following inadvertent injection of CaHA. METHODS: An international group of experts with experience in injection of CaHA and management of vascular complications was convened to develop a consensus on the optimal management of vascular compromise following intra-arterial CaHA injection. The consensus members were asked to provide preventative advice for the avoidance of intravascular injection and to produce a treatment protocol for acute and delayed presentation. To ensure all relevant treatment options were included, the recommendations were supplemented with a PubMed search of the literature. RESULTS: For prevention of intra-arterial CaHA injection, consensus members outlined the importance of a thorough knowledge of facial vascular anatomy and patient history, as well as highlighting potential risk zones and optimal injection techniques. Individual sections document how to recognize the symptoms of vascular occlusion leading to vision loss and tissue necrosis as well as detailed treatment protocols for the management of these events. For impending tissue necrosis, recommendations are provided for early and delayed presentations with treatment protocols for acute and follow-up treatment. A separate section details the treatment options for open and closed wounds. CONCLUSIONS: All physicians should be prepared for the eventuality of intra-arterial injection of a dermal filler, despite its rarity. These consensus recommendations combine advice from aesthetic experts with the latest reports from the published literature to provide an up-to-date office-based protocol for the prevention and treatment of complications arising from intra-arterial CaHA injection.

What affects the prognosis of NOMI patients? Analysis of clinical data and CT findings.

BACKGROUND: Non-occlusive mesenteric ischemia (NOMI) is a mesenteric ischemic disease with considerably high mortality rate, although little has been known about what factors affect the patients' prognosis. The purpose of this study was to investigate prognostic factors of clinical data and computed tomography (CT) findings in patients with NOMI. METHODS: This was a single institutional, retrospective study, reviewing 21 consecutive patients diagnosed with NOMI on angiography. Patients were divided into either ''survivor'' group or ''non-survivor'' group based on their clinical courses 1 month after diagnosis. Clinical information such as laboratory data, Charlson Comorbidity Index, and time from CT to injecting vasodilator was obtained from patients' medical records. Contrast-enhanced CT images were assessed in following items: defect of mural enhancement, pneumatosis intestinalis, hepatic portal venous gas, paralytic bowel dilatation, bowel wall thinning, and diameters of the relevant vessels. RESULTS: Eight patients belonged to ''survivor'' group, whereas eleven were allocated to ''non-survivor'' group. None of CT findings showed significant difference between survivor group and non-survivor group [defect of mural enhancement: 75% and 100% (p = 0.16), pneumatosis intestinalis: 50% and 45.5% (p = 1.00), hepatic portal venous gas: 37.5% and 45.5% (p = 1.00), paralytic bowel dilatation: 12.5% and 63.6% (p = 0.06), and bowel wall thinning: 50% and 45.5% (p = 1.00)]. The diameters of the relevant vessels did not have significant difference either. Time from CT to injecting vasodilator was revealed to be significantly shorter in survivor group [187.5 (122.5-294) min and 310 (187-925.5)] (p = 0.048). None of the other clinical information had significant difference between each group. CONCLUSION: Prompt angiography may be a key to improve the prognosis of NOMI patients.

Risk Comparison of Filler Embolism Between Polymethyl Methacrylate (PMMA) and Hyaluronic Acid (HA).

BACKGROUND: The incidence of vascular complications varies among different fillers. The main purpose of this study was to compare the risk of embolism between PMMA (Artecoll) and hyaluronic acid (HA, Restylane) after artery injection. METHODS: Rabbit ears were injected via the central artery with 0.1 ml PMMA (group A), 0.1 ml HA (group B), 0.2 ml PMMA (group C), or 0.2 mL HA (group D), respectively. The formation of transparent emboli was monitored right after injection. Tissue necrosis and histopathological changes were analyzed on day 7. RESULTS: With 0.1 ml injected volume, PMMA was dispersed within a few minutes and only 5% of the injected ears had mild necrosis on day 7, while HA tended to form obvious transparent emboli, an indication of blood vessel clotting, and 60% of injected ears showed necrosis on day 7. With 0.2 ml injected volume, PMMA had a risk of complete blood vessel clotting in between 0.1 ml PMMA group and 0.1 ml HA group, and 30% of injected ears had necrosis; in contrast, 100% of 0.2 ml HA-injected ears showed transparent emboli and necrosis. The necrosis areas were significantly increased in the HA groups compared with PMMA groups at the same injection volumes. HA injection also caused dilation of small blood vessels. CONCLUSION: At the same injection volume, PMMA had less risk of embolism compared with HA. With increased injection volume, there were increased risks of embolism and necrosis for both PMMA and HA. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Intra-arterial Drug Delivery to the Ischemic Brain in Rat Middle Cerebral Artery Occlusion Model.

Rat transient middle cerebral artery occlusion (tMCAO) model is one of the most commonly used animal models in ischemic stroke studies. In the model, increasing safety and efficacy of therapeutic agent administration, such as stem cells and drugs directly to the ischemic brain using the internal carotid artery (ICA) is essential, because using the common carotid artery (CCA) for injection can close CCA completely and cause many complications after tMCAO surgery. Also, the pterygopalatine artery (PPA) is an arterial branch of the ICA that supplies blood circulation of the external part of the brain and removing the blood circulation of the PPA is required for more complete induction of ischemia to the brain. Herein, we present the insertion of intra-arterial catheter in the ICA via the external carotid artery (ECA) after the PPA in rats subjected to tMCAO surgery.

Unintended intra-arterial injection of contrast of an intracranial CT angiography.

Computed tomography angiography (CTA) is widely used to evaluate intracranial vascular disease. We report a case of intracranial CTA with unintended intra-arterial (IA) injection of contrast due to IA placement of an intravenous cannula, which results in a selective left vertebral artery IA CTA. Knowledge of anatomy is essential in analyzing the whole study and identifying the error. In clinical practice, it is important to avoid and recognize a wrongly placed intravenous cannula. And bolus tracking protocol might play a role as a gatekeeper.

Current Assessment and Management of Retinoblastoma / 임상소아혈액종양

Retinoblastoma is the most common intraocular malignancy in childhood. Diagnosis is currently made by ophthalmologists under general anesthesia as it is the gold standard for intraocular assessment. However, evaluations for extraocular disease are also necessary. Treatment strategies vary according to the disease status. If a single eye is involved, the treatment goal is oriented to the removal of the tumor and prevention of relapse. In bilateral retinoblastoma, the main treatment goal is to save monocular vision and save life. This article will explore the available treatment options for retinoblastoma including enucleation, radiotherapy, local therapy, intravenous chemotherapy, intra-arterial injection and intra-vitreal injections. There were recent advances in our understanding on the genetic pathophysiology of the retinoblastoma protein gene in tumorigenesis, which may help developing future treatment. Early detection of retinoblastoma is important for prolonging survival and improving quality of life.