June 2010 issue of Radiology has published a very significant article, that with wide-ranging implications.
CECT requests are rampant without any definite indications as most studies can be completed without contrast and studies needing contrast usually also need an MRI scan later; so why not dispense with it altogether.

The authors, Loh et al have found 14.3 % patients developing delayed reactions after CECT using Iohexol, which is definitely very high and probably unaccetable.


Delayed Adverse Reaction to Contrast-enhanced CT: A Prospective Single-Center Study Comparison to Control Group without Enhancement

Shaun Loh , MD , MBA
Sepideh Bagheri , MD
Richard W. Katzberg , MD
Maxwell A. Fung , MD
Chin-Shang Li , PhD
Radiology: Volume 255: Number 3—June 2010


Purpose: To prospectively assess the incidence of delayed adverse reactions (DARs) in patients undergoing contrast material–enhanced computed tomography (CT) with the low osmolar nonionic contrast agent iohexol and compare with the incidence of DARs in patients undergoing unenhanced CT as control subjects.
Materials and Methods:
Institutional review board approval and informed written consent for this prospective study were obtained. The study was HIPAA compliant. Patients undergoing CT for routine indications were enrolled from a random next-available scheduling template by an on-site clinical trials monitor. All subjects received a questionnaire asking them to indicate any DAR occurring later than 1 hour after their examination.
Sixteen manifestations were listed and included rash, skin redness, skin swelling, nausea, vomiting, and dizziness, among others. To ensure maximal surveillance, a clinical trials coordinator initiated direct telephone contact for further assessment. Patients suspected of having moderately severe cutaneous reactions were invited to return for a complete dermatologic clinical assessment including skin biopsy, if indicated.
Statistical analysis was performed by using a twosided Wilcoxon-Mann-Whitney test, a logistic regression
utilizing a x 2 test to adjust for sex and age, and a two- sided Fisher exact test.
Results: A total of 539 patients (258 receiving iohexol and 281 not receiving contrast material) were enrolled. DARs were observed in 37 (14.3%) of 258 subjects receiving iohexol and in seven (2.5%) of 281 subjects in the control group ( P , .0001, x 2 test) after adjusting for sex and age. Specifi c manifestations of DARs that were signifi cantly more frequent at contrast-enhanced CT were skin rash ( P = .0311), skin redness ( P = .0055), skin swelling ( P = .0117), and headache ( P = .0246). DARs involving the skin included generalized
rashes of the face, neck, chest, back, and extremities and were often associated with swelling, erythema, and pruritus.
Conclusion: This study substantiates a frequent occurrence of DARs at contrast-enhanced CT compared with that in control subjects. Continued growth in the use of contrast-enhanced CT suggests a need for greater awareness and attention to prevention and management.
q RSNA, 2010
Supplemental material: http://radiology.rsna.org/lookup
/suppl/doi:10.1148/radiol.10091848/-/DC1


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Posterior cerebral artery aneurysms have been managed many a times conservatively.
However, in reality little really solid literature exists as to the subject
Here is a good review of the topic, and according to it endovascular management is the best option among all the three

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A 23 years-old man developed severe right sided proptosis a month after sustaining head injury in a road traffic accident.
His right orbit showed severe chemosis, injection with decreased ocular movement; vision had decreased to 6/18 ft.
Left eye was normal.
A DSA showed a direct type CCF with rent  near the posterior genu of internal carotid artery and vigorous antegrade flow into the cavernous sinus and ophthalmic veins.
GOLD BAL 4 balloon was used to occlude the fistula using a MAGIC coaxial system.
Post procedure angiogram showed complete occlusion of the fistula with immediate reduction in proptosis nad chemosis.
At 3 months patient 's appearance was totally normal with normal ocular movements but with vision still at 6/18 ft.

In May 26, 2010 issue of NEJM, the much awaited paper was published, dealing with a well planned trial directly comparing carotid endarterectomy and carotid stenting
The results are not surprising: both are equally efficacious with minimal and comparable complications except that more heart attacks were seen in CEA group and more 'brain attacks' in CS.

Stenting versus Endarterectomy   for Treatment of Carotid-Artery Stenosis

Thomas G. Brott, M.D., Robert W. Hobson, II, M.D.,* George Howard, Dr.P.H.,
Gary S. Roubin, M.D., Ph.D., Wayne M. Clark, M.D., William Brooks, M.D.,
Ariane Mackey, M.D., Michael D. Hill, M.D., Pierre P. Leimgruber, M.D.,
Alice J. Sheffet, Ph.D., Virginia J. Howard, Ph.D., Wesley S. Moore, M.D.,
Jenifer H. Voeks, Ph.D., L. Nelson Hopkins, M.D., Donald E. Cutlip, M.D.,
David J. Cohen, M.D., Jeffrey J. Popma, M.D., Robert D. Ferguson, M.D.,
Stanley N. Cohen, M.D., Joseph L. Blackshear, M.D., Frank L. Silver, M.D.,
J.P. Mohr, M.D., Brajesh K. Lal, M.D., and James F. Meschia, M.D.,
for the CREST Investigators†
10.1056/nejmoa0912321


ABSTRACT
BACKGROUND
Carotid-artery stenting and carotid endarterectomy are both options for treating
carotid-artery stenosis, an important cause of stroke.
METHODS
We randomly assigned patients with symptomatic or asymptomatic carotid stenosis
to undergo carotid-artery stenting or carotid endarterectomy. The primary compos-
ite end point was stroke, myocardial infarction, or death from any cause during the
periprocedural period or any ipsilateral stroke within 4 years after randomization.
RESULTS
For 2502 patients over a median follow-up period of 2.5 years, there was no significant
difference in the estimated 4-year rates of the primary end point between the stenting
group and the endarterectomy group (7.2% and 6.8%, respectively; hazard ratio with
stenting, 1.11; 95% confidence interval, 0.81 to 1.51; P  =  0.51). There was no differen-
tial treatment effect with regard to the primary end point according to symptomatic
status (P  =  0.84) or sex (P  =  0.34). The 4-year rate of stroke or death was 6.4% with stent-
ing and 4.7% with endarterectomy (hazard ratio, 1.50; P  =  0.03); the rates among symp-
tomatic patients were 8.0% and 6.4% (hazard ratio, 1.37; P  =  0.14), and the rates among

asymptomatic patients were 4.5% and 2.7% (hazard ratio, 1.86; P  =  0.07), respectively.
Periprocedural rates of individual components of the end points differed between the
stenting group and the endarterectomy group: for death (0.7% vs. 0.3%, P  =  0.18), for
stroke (4.1% vs. 2.3%, P  =  0.01), and for myocardial infarction (1.1% vs. 2.3%, P  =  0.03).
After this period, the incidences of ipsilateral stroke with stenting and with endar-
terectomy were similarly low (2.0% and 2.4%, respectively; P  =  0.85).
CONCLUSIONS
Among patients with symptomatic or asymptomatic carotid stenosis, the risk of the
composite primary outcome of stroke, myocardial infarction, or death did not differ
significantly in the group undergoing carotid-artery stenting and the group undergo-
ing carotid endarterectomy. During the periprocedural period, there was a higher risk
of stroke with stenting and a higher risk of myocardial infarction with endarterec-
tomy. (ClinicalTrials.gov number, NCT00004732.)

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Hi all