Hiroshi Kondo

The results of this pilot study suggested that using subtraction CT combined with dynamic contrast-enhanced CT improved diagnostic accuracy in detecting extravasation in pelvic fractures and reduced reading time.

Background/Objectives: Effective management of aneurysmal subarachnoid hemorrhage (aSAH) requires an evidence-based treatment protocol. This study examines the outcomes of a unified, multicenter protocol emphasizing postoperative clazosentan as the first-line treatment for vasospasm. Methods: A standardized protocol prioritizing systemic management with clazosentan for vasospasm was implemented in April 2023. Cases treated between April 2022 and March 2024 were categorized into four groups: preprotocol fasudil treatment (PrF), preprotocol clazosentan treatment (PrC), postprotocol fasudil treatment (PoF), and postprotocol clazosentan treatment (PoC); these groups were analyzed. Results: Among 407 registered cases, 322 were eligible for analysis (PrF, 128; PrC, 69; PoF, 28; PoC, 97). PoC exhibited significantly lower angiographic vasospasm rates and had a lower incidence of symptomatic vasospasm compared with PrF (p = 0.048, p = 0.057). Logistic regression identified the clazosentan protocol as a predictive factor for vasospasm reduction (p = 0.02, OR 0.46 [0.22–0.94]; p = 0.022, OR 0.38 [0.16–0.91]). PoC experienced less fluid retention than the PrC (p < 0.001). Logistic regression confirmed protocol adherence with protocol reduced complications (p < 0.001, OR 0.24 [0.11–0.52]), included fluid retention (p < 0.001, OR 0.088 [0.03–0.29]). In older patients, no significant differences in vasospasm or complications were observed between PrF and PoC, but a trend toward reduced complications was observed in World Federation of Neurosurgical Societies (WFNS) grade V cases. Conclusions: Clazosentan-first protocol effectively reduces vasospasm and complications in aSAH management. It is also safe for older patients and those with WFNS grade V, offering a promising treatment strategy.

Pelvic fractures are severe trauma that can cause hemorrhagic shock. The mortality rate is high when patients fall into shock. Therefore, prompt diagnosis and treatment are necessary. Hemostasis for hemorrhage associated with pelvic fractures is achieved through the mechanical stabilization of the fracture site, preperitoneal pelvic packing, and transcatheter arterial embolization. These techniques are frequently employed in hemodynamically unstable patients presenting with pelvic fractures. Among them, transcatheter arterial embolization is often considered the first-line choice: it is a particularly effective hemostatic method for arterial hemorrhage caused by pelvic fracture. An embolization technique and embolic agents should be considered comprehensively while considering the patient's hemodynamics, angiographic findings, and the urgency of the situation. This article describes the indications, techniques, results, and complications of transcatheter arterial embolization for pelvic fractures.

Among pediatric cases of moyamoya disease (MMD), cerebral ischemic symptoms often progress and worsen rapidly in infants under one year of age; therefore, it is important to treat them as early as possible. However, direct bypass surgery is often technically difficult for infants due to their small blood vessels. Here, we describe our technique to resolve the technical challenges encountered during superficial temporal artery-to-middle cerebral artery (STA-MCA) bypass surgery in infants aged <1 year with MMD, focusing on specific procedures. We performed bilateral STA-MCA and indirect bypass in a 1-year-old girl with MMD and cerebral infarction. Before treatment, a peripherally inserted central venous catheter (PICC) was placed to avoid ischemic attacks associated with crying, dehydration, and malnutrition. All examinations and procedures that would be stressful to the patient, such as blood examinations, were performed using PICC or under sedation. The STA-MCA diameters were 0.8 and 1.2 mm, respectively. After suturing the planned anastomosis with one stitch using an 11-0 monofilament nylon thread, the thread was lifted upward, and the arterial wall was incised. Anastomosis was performed using an 11-0 monofilament nylon thread with 2–4 stitches on each side. The operation was completed without patency problems. Postoperative blood flow improved, and the patient had a good treatment course. Direct bypass for MMD patients aged <1 year is technically challenging; however, the vessels can be connected if the procedure is carefully performed with consideration of the characteristics of the infant’s vessels.

Purpose: This retrospective study of patients with pulmonary arteriovenous malformations aims to assess the efficacy of embolization distal to the origin of the last normal branch of the pulmonary artery.Material and Methods: A total of 30 consecutive patients with 38 untreated pulmonary arteriovenous malformations underwent coil embolization distal to the origin of the last normal branch of the pulmonary artery between September 2015 and October 2021. The median (interquartile range) age of patients (5 males, 25 females) was 59 years (50-68 years old), and the median (interquartile range) sizes of the feeding artery and sac were 2.9 mm (2.3-3.8 mm) and 6.7 mm (5.4-9.7 mm), respectively. The technical success rate, persistence rate, and treatment-related complications were evaluated. Technical success was defined as the inability to identify the draining vein on feeding arteriography after coil embolization. Persistence was assessed using time-resolved magnetic resonance angiography.Results: Coil embolization was successful in all patients (100%). There was no persistence during a median (interquartile range) follow-up period of 23 months (10-45 months) for the 38 pulmonary arteriovenous malformations embolized with coils. No major complications were reported. Only minor complications following embolization occurred in 4 of 36 sessions, including local pain in 2 sessions (6%) and hemosputum in 2 sessions (6%).Conclusions: Embolization distal to the origin of the last normal branch of the pulmonary artery is effective in preventing the persistence of pulmonary arteriovenous malformations.