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PubMed2001

An assessment of the incidence of punctures in latex and non-latex dental examination gloves in routine clinical practice.

OBJECTIVE: To investigate the puncture resistance of a recently introduced non-latex, nitrile dental glove in comparison with a latex glove worn during routine clinical dental procedures. SETTING: Dentists in general dental practice working within the UK during 1999. SUBJECTS AND METHODS: 2,020 gloves worn by five general dental practitioners were examined for punctures following standard clinical use by a water inflation method. Procedures undertaken during glove usage and length of time worn were recorded. RESULTS: Following clinical use, 1.9% of the latex gloves and 5.3% of the nitrile gloves had punctures, a statistically significant difference (P < 0.0001). The puncture resistance of the nitrile gloves was superior to the puncture resistance of previously tested worn non-latex (vinyl) gloves. There was no evidence of a statistically significant difference between operators for the percentage or incidence of punctured gloves (P = 0.787) after correcting for glove type. No statistically significant difference was noted between incidence of puncture in the control, unused gloves (n = 200 for each type) and the gloves examined following clinical use (P = 0.907 for nitrile, P = 0.613 for latex). CONCLUSION: No increase in the number of punctures was noted following clinical use for either glove type. This could be considered to indicate good puncture resistance of the gloves tested in clinical use.

Analysis of Variance↗
PubMed2005

Effect of calcium trisodium DTPA in rats with puncture wound contaminated by 90Y-chloride.

The efficacy of diethylenetriaminepentaacetate calcium trisodium (CaNa(3)DTPA) in a dose of 34.7 micromol kg(-1) as a function of its route of administration was investigated in rats with a puncture wound contaminated by (90)Y-chloride at a concentration of 2.55 MBq kg(-1). Approximately 60% of (90)Y-chloride at a puncture wound was absorbed into the body of rats over 72 h post-puncture and radioactivity in femoral bone increased during the timed-release of (90)Y. Intravenous administration of CaNa(3)DTPA (systemic treatment) at 15 min post-puncture reduced (90)Y at a puncture wound and in bone up to 75.6 and 84.3% of controls, respectively. Direct infiltration of CaNa(3)DTPA into a puncture wound site (local treatment) at 15 min post-puncture diminished radioactivity at the puncture wound and in bone up to 34.9 and 52.5% of controls, respectively. Thus, prompt local treatment may be effective for removing (90)Y from a puncture wound and minimising (90)Y-distribution to bone compared with systemic treatment.

Animals↗
PubMed2006

Comparison of microbiological results of needle puncture vs. superficial swab in infected diabetic foot ulcer with osteomyelitis.

AIM: To study prospectively two methods for the bacteriological diagnosis of osteomyelitis related to diabetic foot ulcer: needle puncture performed across normal skin surrounding the foot ulcer and superficial swabbing of the ulcer. PATIENTS AND METHODS: Diabetic patients with a foot ulcer complicated by bone or joint infection, as detected by X-ray imaging, were included in the study. Ulcer swabbing and needle puncture were performed in each patient. To reach the tissue nearest the bone surface, needle puncture was guided by X-ray imaging and the drop of fluid obtained by aspiration was used for both aerobic and anaerobic bacterial culture. RESULTS: Twenty-one diabetic patients were included. The mean number of microorganisms isolated by needle puncture was significantly lower compared with that obtained by superficial swabbing: 1.09 vs. 2.04 (P < 0.02). Three bacterial species were isolated by needle puncture only in one patient while three or more bacterial isolates were obtained by superficial swabbing in six patients. No bacterial isolate was detected in five patients by needle puncture and in two patients by superficial swabbing. Staphylococcus aureus accounted for 70% of cases (seven patients) when a single bacterial species was obtained by needle puncture. After needle puncture, no wound complication or infection was observed. CONCLUSION: Culture of samples obtained by needle puncture revealed one or two bacterial isolates in two-thirds of diabetic patients with osteomyelitis following foot ulcer. Given the lack of complications, this invasive diagnostic technique should be considered for deep direct sampling in diabetic patients with osteomyelitis related to foot ulcer when surgical debridement is contraindicated or delayed.

Adult↗
PubMed2003

Reliability and performance of innovative surgical double-glove hole puncture indication systems.

During operative procedures, operating room personnel wear sterile surgical gloves designed to protect them and their patients against transmissible infections. The Food and Drug Administration (FDA) has set compliance policy guides for manufacturers of gloves. The FDA allows surgeons' gloves whose leakage defect rates do not exceed 1.5 acceptable quality level (AQL) to be used in operating rooms. The implications of this policy are potentially enormous to operating room personnel and patients. This unacceptable risk to the personnel and patient could be significantly reduced by the use of sterile double surgical gloves. Because double-gloves are also susceptible to needle puncture, a double-glove hole indication system is urgently needed to immediately detect surgical needle glove punctures. This warning would allow surgeons to remove the double-gloves, wash their hands, and then don a sterile set of double-gloves with an indication system. During the last decade, Regent Medical has devised non-latex and latex double-glove hole puncture indication systems. The purpose of this comprehensive study is to detect the accuracy of the non-latex and latex double-glove hole puncture indication systems using five commonly used sterile surgical needles: the taper point surgical needle, tapercut surgical needle, reverse cutting edge surgical needle, taper cardiopoint surgical needle, and spatula surgical needle. After subjecting both the non-latex and latex double-glove hole puncture indication systems to surgical needle puncture in each glove fingertip, these double-glove systems were immersed in a sterile basin of saline, after which the double-gloved hands manipulated surgical instruments. Within two minutes, both the non-latex and latex hole puncture indication systems accurately detected needle punctures in all of the surgical gloves, regardless of the dimensions of the surgical needles. In addition, the size of the color change visualized through the translucent outer glove did not correlate with needle diameter. On the basis of this extensive experimental evaluation, both the non-latex and latex double-glove hole puncture indication systems should be used in all operative procedures by all operating room personnel.

Equipment Design↗
PubMed1987

[Contribution of cytological punctures to the diagnosis of kidney tumors].

Analysis concerned 47 kidney tumours. Puncture was under ultrasonographic control using 22 G needles. The sample was obtained by suction. The authors then describe the technique of fixing and reading of smears. Four types of indications were adopted; diagnostic uncertainty between benign and malignant nature (22 cases), high risk surgical patients in whom a pre-operative histological diagnosis is very desirable (10 cases), search for a primary neoplasm in the presence of metastatic spread (5 cases), routine puncture of tumours seen by ultrasonography (10 cases). Puncture material was uninterpretable in 6 cases. In 26 cases of puncture-cytology could be compared with those of histological examination (nephrectomy or surgical biopsy). 3 puncture-cytology results were un-interpretable, whilst in 21 cases the correlation was perfect (17 malignant tumours and 4 benign tumours). In 1 case puncture-cytology led to suspicion of the malignant nature of the lesion. Puncture cytology was erroneous in one case (a malignant tumour confused with an angiomyolipoma). In 21 cases no sample was obtained and it was not possible to establish the correlation between cytological and histological results. Amongst these 21 cases 3 were uninterpretable whilst in 18 there was no evidence of error on the basis of the subsequent clinical course. No complications were seen and in particular no abdominal wall dissemination. Sensitivity of the method was of the order 80 to 87%. Interpretation of puncture-cytology is difficult in urothelial carcinomas, renal adenoma and oncocytoma. By contrast puncture-cytology is particularly reliable in angiomyolipoma and metastatic lesions of the kidney.

Biopsy, Needle↗
PubMed2006

Transnasal puncture based on echographic sinusitis evidence in mechanically ventilated patients with suspicion of nosocomial maxillary sinusitis.

OBJECTIVE: The aim of this prospective study was to evaluate the value of sinus echography results to directly indicate a transnasal puncture in intubated patients with suspicion of nosocomial maxillary sinusitis. DESIGN: prospective clinical investigation. SETTING: medical intensive care unit. PATIENTS: sixty patients undergoing intubation and mechanical ventilation more than 2 days, with a clinical suspicion of maxillary sinusitis with purulent nasal discharge. INTERVENTIONS: 120 sinuses were examined by sinus ultrasound. The image defined as normal was an acoustic shadow arising from the front wall. Two levels of positive echography were described: (1) a partial sinusogram was defined as the visualization of the hyperechogenic posterior wall of the sinus; and (2) a complete sinusogram was defined as the hyperechogenic visualization of posterior wall and the extension by the internal and external walls of the sinus. When sinus ultrasound was positive, a transnasal puncture was performed the same day. The transnasal puncture was positive if a fluid was obtained from sinus aspiration. The transnasal puncture was negative if there was no aspirated material. MEASUREMENTS AND RESULTS: sinus ultrasound was positive in 84 cases (54 complete sinusograms and 30 partial sinusograms). Seventy-eight of 84 transnasal punctures were positive. Sensitivity of a sinusogram for obtaining positive transnasal puncture was 100%, and specificity was 86% (100% in case of complete sinusogram) in a clinically selected population. The only six negative transnasal punctures were performed in patients with partial sinusogram. CONCLUSIONS: Ultrasound sinusitis evidence seems to be of value to indicate and perform a transnasal puncture directly, avoiding CT exam.

Aged↗
PubMed2000

Puncture forces of solid organ surfaces.

BACKGROUND: In this experimental study, we measured the force needed to puncture the liver (low elastin) and the spleen (high elastin). The surface displacement preceding puncture was also measured. These data are relevant to an understanding of surgical technique and are essential to the development of electronic surgical simulators. METHODS: Controlled puncture experiments were performed on intact organs harvested from pigs and sheep, as well as on their surface capsules following removal and suspension at zero strain and at three increasing levels of prestrain. The biomechanical data were compared with information obtained from histological studies. RESULTS: The spleen has a higher puncture force than the liver and suffers greater displacement before puncture (p < 0.05). Prestrain decreases displacement before puncture (p < 0.05) but has no effect on puncture force. CONCLUSION: The higher puncture force and displacement of spleen, as compared with liver, is probably due to its higher elastin content.

Animals↗
PubMed2006

Holmium: yttrium-aluminum-garnet laser puncture of ureteroceles in neonatal period.

OBJECTIVES: The use of the holmium:yttrium-aluminum-garnet (YAG) laser to incise a ureterocele in children has been reported. However, its use to puncture ureteroceles in neonates has not. Therefore, we evaluated the effectiveness and safety of ureterocele puncture using a holmium-YAG laser in neonatal patients. METHODS: We reviewed our experience of all neonates (ie, children younger than 28 days old) who underwent transurethral puncture of a ureterocele. The preoperative data collected included age at presentation, mode of presentation, ureterocele location, and weight and age at the procedure. A holmium:YAG laser was used to incise the ureterocele, and a 200, 365, or 550-microm laser fiber was passed through a 6F or 7.5F cystoscope. RESULTS: A total of 4 neonates (2 boys and 2 girls) underwent transurethral holmium laser puncture of five ureteroceles. All patients were initially diagnosed with prenatal ultrasound findings confirmed after birth with additional imaging. The mean age at the initial puncture was 13.8 days, with a mean patient weight of 3.9 kg. The mean follow-up was 2.8 years (range 1.7 to 3.4). Four (80%) of five ureteroceles were adequately decompressed after one attempt. One patient required a second puncture of the ureterocele at 46 days of age because of incomplete decompression. None of the patients experienced an intraoperative or postoperative complication, including new vesicoureteral reflux after laser puncture. CONCLUSIONS: Holmium:YAG laser puncture of ureterocele is a safe, efficacious, and viable option for children in the neonatal period. However, this technique in these young children requires additional evaluation.

Decompression, Surgical↗
PubMed1999

Long-term outcome of transurethral puncture of ectopic ureteroceles: initial success and late problems.

PURPOSE: We studied the long-term outcome of transurethral puncture of ectopic ureteroceles specifically associated with duplex systems. MATERIALS AND METHODS: We retrospectively reviewed the records of patients who underwent transurethral puncture of an ectopic ureterocele. Study exclusion criteria were orthotopic, bilateral and prolapsing ureteroceles. RESULTS: We identified 19 girls and 2 boys, of whom 11 presented with prenatal hydronephrosis and 10 presented with urinary tract infection. Mean age at puncture was 5 months (range 0.5 to 60). Preoperatively voiding cystourethrography revealed no reflux in 7 patients, isolated ipsilateral lower pole reflux in 8, and bilateral and/or contralateral reflux in 6. Postoperatively studies initially showed no reflux in 8 cases but in 4 of the 8 reflux recurred up to 4 years after puncture. In 10 patients (48%) reflux developed into the ureterocele and upper pole segment. Repeat puncture was required 1 to 13 months after the initial procedure in 4 patients for persistent or recurrent upper pole hydroureteronephrosis. Subsequent open surgery was required in 15 of the 21 cases (71%), including ureterocele excision with ureteral reimplantation in 14. Of the children 10 and 4 underwent open surgery for recurrent urinary tract infection and progressive reflux, respectively, while 1 underwent ureteroureterostomy for progressive upper pole reflux. No patient underwent upper pole nephrectomy. Of the remaining 6 patients 4 have low grade reflux. CONCLUSIONS: Transurethral puncture of ectopic ureteroceles provides effective short-term correction of upper pole obstruction but it is not definitive therapy in the majority of cases. Most children still require open surgery. In patients without reflux after the puncture procedure new onset, recurrent or progressive reflux may later develop with extended followup. Repeat puncture may be required to ensure adequate decompression in a minority of cases, as in the 20% in our series.

Child, Preschool↗
PubMed1999

The effect of lumbar puncture stress on dopamine and serotonin metabolites in human cerebrospinal fluid.

In order to examine concentrations of cerebrospinal fluid (CSF) neurochemicals, the technique of lumbar puncture is typically used. However, the effect of the intrinsic stress of undergoing a lumbar puncture on CSF monoamine concentrations in humans has not yet been established. We used lumbar puncture followed 3 h later by continuous CSF sampling to examine the effect of lumbar puncture on levels of the dopamine and serotonin metabolites homovanillic acid (HVA) and 5-hydroxyindoleacetic acid (5-HIAA), respectively. Additionally, we examined the effect of lumbar puncture on the CSF HVA to 5-HIAA ratio. Immediately post lumbar puncture, CSF concentrations of HVA and 5-HIAA were, respectively, only 51 and 54% of the mean levels detected hours later. However, the HVA to 5-HIAA ratio remained stable during lumbar puncture. While HVA and 5-HIAA levels in CSF obtained via lumbar puncture reflect highly variable responses to the stress of the procedure, the ratio of these metabolites is unaffected.

Adult↗
PubMed1992

The association between meningitis and dural puncture in bacteremic rats.

Clinicians have long been concerned that performance of spinal anesthesia during a period of bacteremia may result in the subsequent development of meningitis. In order to determine whether such an association exists, percutaneous dural puncture was performed in 40 animals during a period of Escherichia coli bacteremia. Twenty-four hours later, spinal fluid was obtained for final analysis by surgically draining the cisterna magna. Twelve animals had E. coli recovered from the surgically drained spinal fluid. Only animals with a circulating bacterial count of at least 50 CFU/ml developed meningitis. Microscopic examination of the brains and spinal cords of animals with infected cerebrospinal fluid showed evidence of central nervous system infection. Bacteremic animals not undergoing percutaneous dural puncture always had sterile spinal fluid (n = 40). Cisternal puncture in the absence of bacteremia did not result in infection (n = 30). Treatment with a single dose of gentamicin before the dural puncture eliminated the risk of meningitis after dural puncture in 30 bacteremic animals. These results demonstrate that dural puncture is associated with the development of meningitis in rats, provided the animals are bacteremic at the time of the puncture. However, antibiotic treatment before the dural puncture appears to eliminate this risk.

Anesthesia, Spinal↗
PubMed1994

Effect of needle puncture on morphine and lidocaine flux through the spinal meninges of the monkey in vitro. Implications for combined spinal-epidural anesthesia.

BACKGROUND: Combined spinal-epidural anesthesia is a technique growing in popularity. However, there have been no attempts to investigate the risk of epidural drug reaching the subarachnoid space in high concentration by passing through the meningeal hole left by the spinal needle. This study begins to address this question by quantitating the flux of morphine and lidocaine through the spinal meninges of the monkey in vitro after puncture with three different-sized needles. METHODS: Spinal meningeal tissue from anesthetized monkeys was mounted in a diffusion cell and drug flux was measured through intact tissue and through tissue punctured with a 27-G Whitacre, a 24-G Sprotte, and an 18-G Tuohy needle. RESULTS: The flux of morphine through the meningeal tissue was significantly increased by puncture with each of the study needles. The flux of lidocaine was significantly increased only by puncture with the 24-G Sprotte and 18-G Tuohy needles. The flux of morphine through intact tissue was less than the flux of lidocaine through intact tissue. In contrast, the flux of morphine and lidocaine were the same through tissue punctured with the study needles. The magnitude of the drug flux through the needle puncture was a function of the diameter of the study needle. CONCLUSIONS: Epidural anesthesia after accidental or intentional puncture of the spinal meninges has occasionally resulted in high spinal blocks and total spinal anesthesia. This study suggests that drug movement through the meningeal hole is responsible for this complication and that the risk may be decreased by using the smallest possible needle to puncture the meninges.

Anesthesia, Epidural↗
PubMed2003

Dural tissue trauma and cerebrospinal fluid leak after epidural needle puncture: effect of needle design, angle, and bevel orientation.

BACKGROUND: The effects of epidural needle design, angle, and bevel orientation on cerebrospinal fluid leak after puncture have not been reported. The impact of these factors on leak rate was examined using a dural sac model. Dural trauma was examined using scanning electron microscopy. METHODS: Human cadaveric dura, mounted on a cylindrical model, was punctured with epidural needles using a micromanipulator. Tissue was punctured at 15 cm H2O (left lateral decubitus) system pressure, and leak was measured at 25 cm H2O (semisitting) pressure. Leak rates and trauma were compared for the following: (1) six different epidural needles at 90 degrees, bevel parallel to the dural long axis; (2) 18-gauge Tuohy and 18-gauge Special Sprotte epidural needles, 30 degrees versus 90 degrees; (3) 18-gauge Tuohy, bevel perpendicular versus parallel to the dural long axis. RESULTS: With the 90 degrees puncture, bevel parallel, the greatest leak occurred with a 17-gauge Hustead (516 +/- 319 ml/15 min), and the smallest leak occurred with a 20-gauge Tuohy (100 +/- 112 ml/15 min; P = 0.0018). A 20-gauge Tuohy puncture led to statistically significant reductions in leak (P value range, 0.0001-0.0024) compared with all needles except the Special Sprotte. With the 30 degrees versus 90 degrees angle, 30 degrees punctures with an 18-gauge Tuohy produced nonstatistically significant leak reductions compared with the 18-gauge Tuohy at 90 degrees. The puncture angle made no difference for the Special Sprotte. Nonsignificant reductions were found for the Special Sprotte compared with the Tuohy. With the 18-gauge Tuohy bevel orientation, perpendicular orientation produced nonstatistically significant reductions in leak compared with parallel orientation. CONCLUSIONS: Cerebrospinal fluid leak after puncture was influenced most by epidural needle gauge. Leak rate was significantly less for the 20-gauge Tuohy needle.

Anesthesia, Spinal↗
PubMedDate not supplied

An MRI study of lumbar puncture headaches.

We studied 11 patients undergoing a routine lumbar puncture to determine if there were cerebrospinal fluid leaks at the puncture site and whether the maximum volume of leakage correlates with a lumbar puncture headache. Patients completed a headache questionnaire before and after the lumbar puncture. Limited magnetic resonance imaging of the lumbar spine was obtained 8 to 36 hours after the lumbar puncture and two patients also had later imaging. In a blinded fashion, the largest diameter of cerebrospinal fluid leakage into the paraspinous area was determined from T2 weighted magnetic resonance images and the maximum possible fluid volume was calculated. Six patients had a small cerebrospinal fluid leakage (< 10 mL), two had a medium leakage (10 to 110 mL), and three had a large leakage (> 110 mL). The volume of cerebrospinal fluid leakage did not correlate with occurrence of a lumbar puncture headache. The study demonstrates that cerebrospinal fluid usually leaks into the paraspinous area after a lumbar puncture, but the volume of escaped fluid does not correlate with a lumbar puncture headache.

Cerebrospinal Fluid↗
PubMed2002

The role of lumbar puncture in children with suspected central nervous system infection.

BACKGROUND: The use of the lumbar puncture in the diagnosis of central nervous system infection in acutely ill children is controversial. Recommendations have been published but it is unclear whether they are being followed. METHODS: The medical case notes of 415 acute medical admissions in a children's hospital were examined to identify children with suspected central nervous system infection and suspected meningococcal septicaemia. We determined whether lumbar punctures were indicated or contraindicated, whether they had been performed, and whether the results contributed to the patients' management. RESULTS: Fifty-two children with suspected central nervous system infections, and 43 with suspected meningococcal septicaemia were identified. No lumbar punctures were performed in patients with contraindications, but only 25 (53%) of 47 children with suspected central nervous system infection and no contraindications received a lumbar puncture. Lumbar puncture findings contributed to the management in 18 (72%) of these patients, by identifying a causative organism or excluding bacterial meningitis. CONCLUSION: The recommendations for undertaking lumbar punctures in children with suspected central nervous system infection are not being followed because many children that should receive lumbar punctures are not getting them. When they are performed, lumbar puncture findings make a useful contribution to the patients' management.

Adolescent↗
PubMed1989

Treatment of simple renal cysts by percutaneous puncture and instillation of bismuth-phosphate.

One hundred and fifty-six patients with simple renal cysts had either a percutaneous puncture alone, percutaneous puncture combined with bismuth-phosphate instillation or no intervention at all. At follow-up, 25% of the cysts in which there was no intervention had grown and the mean size showed a slight increase. Ten per cent of the cysts which were only percutaneously punctured disappeared, while the mean size was reduced up to 24 months after puncture. Later, there was no statistically significant difference in change in mean size between punctured cysts and cysts that had no intervention. When puncture was combined with bismuth-phosphate instillation, a gradual reduction was seen in the mean size during the entire follow-up time and 44% of the cysts disappeared. Thirty-six or more months after puncture and instillation, the mean size was only 21% of the original size. It was concluded that percutaneous puncture combined with a bismuth-phosphate instillation is a meaningful treatment of simple renal cysts.

Aged↗
PubMed1998

Post lumbar puncture headache: is bed rest essential?

Headache following lumbar puncture is a well known and well described complication. Various manoeuvres have been tried to prevent post lumbar puncture headache--the commonest being bed rest for 4 to 24 hours following lumbar puncture, though its value is questionable. Randomised controlled clinical trial was done to evaluate the effect of 24 hours bed rest on the incidence and severity of post lumbar puncture headaches. Two hundred and eight patients were randomly allocated to either the ambulant or the bed rest group. Patients were interviewed by a single investigator on days 0, 1, 2 and 7 about the presence and nature of headache. Other relevant clinical and laboratory data pertaining to the lumbar puncture was collected. The overall incidence of post lumbar puncture headache was 17%; 15% in the ambulant and 18% in the bed rest group. Of the patients who had headaches, severe headache was observed in 57% in the ambulant and 12% in the bed rest group (p = 0.02). Other variables did not alter the outcome of headaches. Bed rest does not appear to alter the incidence of post lumbar puncture headaches, but reduces the severity in those who get headaches, after a lumbar puncture.

Adolescent↗
PubMed2001

Fluoroscopy-guided lumbar puncture: decreased frequency of traumatic tap and implications for the assessment of CT-negative acute subarachnoid hemorrhage.

BACKGROUND AND PURPOSE: In patients with suspected subarachnoid hemorrhage (SAH) and negative CT findings, the iatrogenic introduction of RBCs into the CSF during lumbar puncture may lead to a misdiagnosis. We tested the hypothesis that the risk of traumatic lumbar puncture is lower with the fluoroscopy-guided technique than with the standard bedside technique. METHODS: Data were collected retrospectively from two populations: adult inpatients undergoing standard bedside lumbar puncture for any reason and adult patients undergoing fluoroscopy-guided lumbar puncture for myelography. Patients with SAH and CSF samples with significant abnormalities other than erythrocytosis (ie, CSF leukocytosis, xanthochromia, or elevated protein) were excluded. In all, 1489 bedside procedures and 723 fluoroscopy-guided procedures met the criteria. RESULTS: We found a significant difference in the level of iatrogenic CSF erythrocytosis produced by the two procedures. Using a cutoff of 1000 cells/mm(3), the frequency of traumatic lumbar puncture was 10.1% for bedside lumbar puncture and 3.5% for fluoroscopy-guided lumbar puncture. With fluoroscopic guidance, the frequency of a traumatic tap varied significantly with the operator, ranging from 0% to 24%. CONCLUSION: The use of fluoroscopy-guided lumbar puncture in patients with suspected SAH and negative CT findings should reduce the frequency of false-positive diagnoses of acute SAH as well as the number of unnecessary angiograms for patients with suspected SAH but no underlying intracranial vascular malformation.

Fluoroscopy↗