Interventional Radiology, Surat

Interventional Radiology, Surat IR is a minimally invasive alternative to open surgery that uses radiological image guidance to aid


Interventional Radiology, Surat


Strokes can also be caused by a blockage in blood flow. This blockage causes a lack of blood flow to portions of the brain. The brain injury is called ischemia (literally, lack of blood).

During a stroke, one or more areas of the brain can be damaged. Depending upon the area affected, a person may lose the ability to move one side of the body, the ability to speak, the ability to see normally, or a number of other functions. The damage may be temporary or permanent, and the function may be partially or completely lost. A person's long term outcome depends upon MOW MUCH brain is damaged, HOW QUICKLY treatment begins, and a number of other factors.

EARLY TREATMENT and PREVENTIVE measures can reduce the brain damage that occurs as a result of a stroke.

The treatment of a stroke depends upon the type of stroke (eg, ischemic or hemorrhagic), the time since the first stroke symptoms occurred, and the patient's underlying medical problems.

VERY EARLY TREATMENTS — The goal of treatment is to restore blood flow to the affected area of the brain as quickly as possible, which means WITHIN THE FIRST FEW HOURS after the stroke begins. The main very early treatments for ischemic stroke are:
●Intravenous thrombolytic ("clot buster") therapy with alteplase
●Intra-arterial mechanical thrombectomy (opening of the blocked artery) with stent retriever devices
Both thrombolytic therapy and mechanical thrombectomy require care in a hospital that can coordinate emergency services, rapid consultation with a neurologist (a physician who specializes in the brain), interventional radiologist (a physician who specializes in minimally invasive treatment), intensive care services, and brain and vascular imaging with CT or MRI scans.

IV THROMBOLYTIC THERAPY — Intravenous thrombolytic therapy uses a medication called tissue plasminogen activator (tPA, alteplase) that is injected into a vein. Alteplase works to dissolve clots that are blocking blood flow within arteries of the brain.

The benefit of thrombolytic treatment SLOWLY DECREASES over several hours. Thus, the earlier the treatment is given after the stroke begins, the more likely the artery can be opened.

MECHANICAL THROMBECTOMY — Intra-arterial mechanical thrombectomy is a treatment that uses a catheter containing a device called a stent retriever. The catheter is placed within an artery to the brain and guided to the clot that is causing the stroke symptoms. This stent retriever device can restore blood flow to the brain by capturing and removing the clot blocking the large artery.

Mechanical thrombectomy can be beneficial if it is given WITHIN SIX HOURS from the start of the stroke symptoms. It is used only for patients who have a blockage in one of the LARGE ARTERIES within the brain, so not all patients with ischemic stroke will need this type of treatment.

For those who do need it, the sooner mechanical thrombectomy is started, the more likely that it will help. In randomized controlled trials, patients treated with mechanical thrombectomy had a significantly higher rate of functional independence compared with patients who received the usual treatment, which was generally intravenous thrombolytic therapy.

OTHER EARLY TREATMENTS — The medicines used for the early treatment of ischemic stroke are aspirin and anticoagulants.

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Endovascular treatment of stroke are now the treatment of choice in large vessel occlusive ischemic stroke

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The first line of defense for an ischemic stroke is the intravenous delivery of tissue plasminogen activator (tPA) within 3 to 4.5 hours of stroke symptoms. Administering tPA dissolves the blood clot and re-establishes blood flow to the brain.

Stent retrieval technology can help remove blood clots for ischemic stroke patients.But in stroke patients battling large blood clots, the new guidelines recommend the treatment of a stent retrieval device if a blood clot should not dissolve after tPA is given.

A stent retrieval device is designed like a mesh cage and is delivered by catheter through the blocked artery, where it expands to capture the blood clot and return normal blood flow to the brain.

For a stroke patient who is at least 18 years old, and is experiencing an acute, severe stroke, with a blood clot blocking a large artery supplying blood to the brain, the new guidelines recommend treatment with a stent retrieval device if:

• The patient had no significant disability prior to the stroke
• The patient received tPA within 4.5 hours of stroke symptoms
• The patient’s brain on the side of the stroke is not permanently damaged
• The patient can receive treatment within 6 hours of stroke symptoms

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Flow Diversion for Aneurysms with Stents

What is flow diversion?

Flow diversion is an endovascular technique whereby instead of placing a device inside the aneurysm sac, such as coils, the device is placed in the parent blood vessel to divert blood flow away from the aneurysm itself.

How is flow diversion performed?

During a flow-diversion procedure, a microcatheter is navigated past the aneurysm without having to enter the aneurysm. Then, the flow-diverting device is deployed across the neck of the aneurysm in the parent blood vessel where the aneurysm is present.

Almost immediately the blood flow to the aneurysm is reduced, and the complete closure of the aneurysm occurs between 6 weeks to 6 months after the procedure.

Reasons for having flow diversion performed

A flow diversion procedure may be performed to treat an unruptured brain aneurysm. Flow diversion is one method of removing the need to enter the aneurysm, which is the most dangerous part of endovascular treatment of aneurysms. The risk of rupturing the aneurysm during surgery is greatly diminished by not placing a device inside the aneurysm.

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A carotid-cavernous fistula (CCF) results from an abnormal communication between the arterial and venous systems within the cavernous sinus in the skull. It is a type of arteriovenous fistula. As arterial blood under high pressure enters the cavernous sinus, the normal venous return to the cavernous sinus is impeded and this causes engorgement of the draining veins, manifesting most dramatically as a sudden engorgement and redness of the eye of the same side.


CCF may form following closed or penetrating head trauma, surgical damage, rupture of an intracavernous aneurysm, or in association with connective tissue disorders, vascular diseases and dural fistulas.


Divided into low-flow or high-flow, traumatic or spontaneous and direct or indirect. The traumatic CCF typically occurs after a basal skull fracture.

The spontaneous dural cavernous fistula which is more common usually results from a degenerative process in older patients with systemic hypertension and atherosclerosis.

Direct fistulas occur when the Internal Carotid artery (ICA) itself fistulizes into the Cavernous sinus whereas indirect is when a branch of the ICA or External Carotid artery (ECA) communicates with the cavernous sinus.

Type Description
A Fistulous supply from the internal carotid artery
B Supply from dural branches of internal carotid artery
C from meningeal branches of ext carotid artery
D combined ICA+ECA


- dilated blood vessels in the eye in CCF
- bruit (a humming sound within the skull due to high blood flow through the arteriovenous fistula)
- progressive visual loss
- pulsatile proptosis or progressive bulging of the eye due to dilatation of the veins draining the eye
- Pain

Patients usually present with sudden or insidious onset of redness in one eye, associated with progressive proptosis or bulging. They may have a history of similar episodes in the past.


This is based on MRI scan, magnetic resonance angiography and CT scan. A cerebral digital subtraction angiography (DSA) enhances visualization of the fistula.

CT scans classically show an enlarged superior ophthalmic vein, cavernous sinus enlargement ipsilateral (same side) as the abnormality and possibly diffuse enlargement of all the extraocular muscles resulting from venous engorgement.
Selective arteriography is used to evaluate arteriovenous fistulas.


The mainstay of treatment for CCF is endovascular therapy.

This may be transarterial (mostly in the case of direct CCF) or transvenous (most commonly in indirect CCF). Occasionally, more direct approaches, such as direct transorbital puncture of the cavernous sinus or cannulation of the draining superior orbital vein are used when conventional approaches are not possible. Spontaneous resolution of indirect fistulae has been reported but is uncommon. Staged manual compression of the ipsilateral carotid has been reported to assist with spontaneous closure in selected cases.

Direct CCF may be treated by occlusion of the affected cavernous sinus (coils, balloon, liquid agents), or by reconstruction of the damaged internal carotid artery (stent, coils or liquid agents).

Indirect CCF may be treated by occlusion of the affected cavernous sinus with coils, liquid agents or a combination of both.


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Balloon-occluded Retrograde Transvenous Obliteration (BRTO)

What is BRTO?

Portal hypertension refers to high blood pressure in the liver. One of the major possible complications of portal hypertension is gastric variceal bleeding. Varices are dilated vessels which may rupture, causing variceal bleeding. Gastric variceal bleeding describes the bleeding that occurs when dilated vessels in the stomach rupture, and is associated with high morbidity and mortality rates.

BRTO is a minimally invasive technique that is used to treat gastric variceal bleeding. The procedure involves blocking the dilated vessels, reducing the risk of rupture. It can be used in addition to or as an alternative to TIPS, which is the primary treatment for gastric varices. TIPS aims to relieve the pressure on the dilated vessels by creating new connections between blood vessels in the liver using a shunt.


How does the procedure work?

The interventional radiologist will insert a balloon catheter (a thin, flexible tube with a tiny balloon at one end) through a vein in your thigh or neck and guide the catheter to the liver using fluoroscopy for guidance. The catheter is then directed to the gastrorenal or gastrocaval shunt and the balloon is expanded to block the shunt.

The interventional radiologist will then perform a venography, which is a type of imaging technique in which X-rays are used to see the vessels clearly. This will allow the interventional radiologist to confirm exactly which vessels need to be treated and if there are any other abnormal or dilated vessels which have not previously been identified. A medication will then be injected into the dilated vessels through the catheter, until they are completely filled. This medication will remain in the vessel for a short period of time, and will then be removed under fluoroscopy.

Another venography will then be performed, to confirm that the blood flow in the shunt has stopped. Finally, the balloon will be deflated and the interventional radiologist will withdraw the catheter.

Why perform it?

You may be advised to undergo this procedure if you are at risk of or already have gastric variceal bleeding and hepatic encephalopathy as well as a gastrorenal shunt. Hepatic encephalopathy refers to the worsening of brain function that is caused by a damaged liver.

Although TIPS has been considered the standard therapy for gastric varices that have been unresponsive to other treatments, recent reports have stated that BTRO is a less invasive and more effective way to manage varices than shunt surgery or TIPS. TIPS does not always cause the disappearance of gastric varices, while BRTO can in most cases completely destroy these vessels.

BRTO has tended to be used to prevent gastric variceal bleeding. It is also an effective therapy for sclerosis (narrowing) of new portosystemic shunts with the additional complication of hepatic encephalopathy. One of the greatest advantages of BRTO is its preservation of liver function. Moreover, the increase of blood flow in BRTO can also improve liver function in cases where the patient has cirrhosis (scarring of the liver).

What are the risks?

Procedure-related complications are minor and include bleeding and infection. In rare cases, the blockage of the blood to the gastric varices can further increase the pressure on the liver, causing damage to the liver.

The most serious complications of the procedure, however, are related to the medication used to block the vessels, which is called ethanolamine oleate. Inflow of a relatively large amount of ethanolamine oleate can lead to serious complications. These complications include pulmonary embolism (blockage in a lung’s main artery), fluid in or around the lungs, hypersensitivity, fever, problems with blood flow to the heart and the formation of small blood clots in vessels throughout the body. Ethanolamine oleate also causes haemolysis, which is the rupturing of red blood cells. To prevent this from occurring, only a low dose of the medication is used.


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ACUTE PULMONARY EMBOLISM (PE) is a life-threatening condition with a mortality of 15% at 3 months; in-hospital mortality rate for massive PE is >50% while submassive PE is 6% to 8%.

Percutaneous interventions are indicated if systemic thrombolysis is contraindicated or urgent recanalization is required

Goals: removal of obstructing thrombi from main or lower lobe pulmonary arteries, facilitate right ventricular recovery, improve symptoms and survival

1) catheter-directed thrombolysis (CDT)
2) pharmacomechanical thrombolysis (PMT)

1) thrombus fragmentation
2) mechanical thrombectomy

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MVT refers to a blood clot that blocks off (occludes) the mesenteric vein, which is located in the tissue that connects the intestine to the back of the abdominal wall.

Incidence and Prevalence:

MVT is a rare but often lethal form of intestinal ischemia and makes up 5% to 15% of all cases of acute mesenteric ischemia.

While the true prevalence is unknown, the incidence of symptomatic mesenteric thrombosis is reported to be 2 per 100,000 individuals. This condition accounts for 0.006% of hospital admissions, and is found in approximately 0.001% of exploratory laparotomies (Tessier).

Causation and Known Risk Factors

Women who use estrogen-containing oral contraceptives and smoke are at greater risk for mesenteric thrombosis.

Individuals who have undergone previous abdominal surgery and individuals who suffer from hyper-coagulable states are at increased risk for mesenteric thrombosis. Other predisposing factors include inflammation, such as pancreatitis; portal hypertension; enlargement of the spleen (splenomegaly); sickle cell disease; decompression sickness; paroxysmal nocturnal hemoglobinuria; malignancy; blunt abdominal trauma; and visceral infection. However, in half the cases, no underlying cause is found.


A high index of suspicion based upon history and clinical findings is necessary to make an early diagnosis.

History: Individuals with mesenteric thrombosis are usually asymptomatic until the onset of late complications. Once symptoms begin, abdominal pain is the most common complaint. The pain is usually vague and slowly progressive, with eventual localization over the affected segment of bowel. Individuals may also complain of nausea, vomiting, diarrhea, and anorexia.

Physical exam: Upon examination, a low grade fever may be noted. Examination of the heart may reveal tachycardia. Other physical findings may include abdominal tenderness, decreased bowel sounds, abdominal distension, and blood in the stool. Late in the course of the disease, paracentesis may demonstrate bloody peritoneal fluid.

Tests: Laboratory examinations do more to suggest rather than confirm the diagnosis of mesenteric thrombosis. Recommended studies include prothrombin time (PT), activated partial thromboplastin time (aPTT), complete blood count (CBC), and chemistries (which may show metabolic acidosis). In general, laboratory studies are unremarkable, though a leukocytosis with a left shift and elevated lactic dehydrogenase are usually present.

Definitive diagnosis of mesenteric venous thrombosis relies upon the demonstration of thrombus within the mesenteric veins on imaging studies. Although magnetic resonance (MR) venography is overall the most accurate imaging study for the diagnosis of mesenteric venous thrombosis, we suggest computed tomography (CT) of the abdomen as an initial screening study for acute or subacute mesenteric venous thrombosis. Abdominal CT more reliably demonstrates findings of focal or segmental bowel-wall ischemia, in addition to excluding other causes of acute abdominal pain, and is inexpensive and widely available. For patients in whom the diagnosis of acute mesenteric ischemia is uncertain, but a suspicion remains high, angiography (CTA, MRA, or catheter based) should be performed, though uncommonly necessary. The diagnosis will necessarily be made in the operating room in patients who present with signs of bowel infarction.


Patients with clinical signs of bowel infarction require surgical intervention with an open approach rather than laparoscopic exploration. The extent of bowel edema and resulting abdominal distention make a laparoscopic approach difficult, and insufflation of the abdomen can exacerbate mesenteric venous hypertension. There should be a low threshold for leaving the abdomen open to facilitate second-look operation. Whenever the viability of the intestine is in question, a second-look operation should be planned and performed as scheduled.

For patients with acute or subacute mesenteric venous thrombosis without indications for surgery, we initiate systemic anticoagulation to minimize extension of thrombus, rather than expectant management alone (includes bowel rest and decompression, fluid therapy and serial abdominal examination).


Prophylactic antibiotics are given to minimize bacterial translocation.


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An interventional radiological technique to occlude the arterial supply to the uterus and is performed for various reasons.

Practised for more than 20 years for controlling haemorrhage following delivery / abortion, in ectopic or cervical pregnancy, gestational trophoblastic disease or carcinoma cervix
The technique was first reported as an effective intervention for fibroids in 1995 when Ravina et al noted that several women with symptomatic leiomyomata who underwent UAE as a pre-hysterectomy treatment had significant clinical improvement to an extent that hysterectomy was no longer required.
It is now estimated that more than 100,000 UAE procedures may have been performed so far for the treatment of fibroids.

1) post partum hemorrhage
2) intramural fibroids
3) dysfunctional uterine bleeding
4) adenomyosis
5) uterine artery pseudoaneurysm(s)
6) uterine AVM

People with uterine fibroids traditionally undergo total abdominal, vaginal or laparoscopic assisted hysterectomies around the world. In less developed and more populous countries like India, the numbers may be even higher. There is an increasing need for non-invasive or less invasive alternatives for uterine fibroids and dysfunctional bleeding.

Pre-procedural evaluation
a thorough evaluation of patients symptoms and signs in consultation with a gynaecologist
pelvic ultrasound and MRI
pap smear and endometrial biopsy
relevant history of other medical problems

The type of embolic agent selected will depend on the indication.
A] Fibroids
- PVA (300-350 microns)
- embospheres
B] Post-partum haemorrhage or vaginal bleeding
- gel foam particles
- coils (occasionally)
- n-butyl-cyanoacrylate (glue)

For vaginal bleeding
- alleviates need for emergency hysterectomy
- resumption of menstruation
- successful pregnancy after UAE for PPH
- unsuspected abnormalities treated during UAE for PPH
For fibroids
- menorrhagia / dysmenorrhoea and metrorrhagia improve in 70-95% of cases
- hospital stay is rarely >48 hours
- patients are often back to work within 10 days
- no post laparotomy complications
- mean uterine volume reduction by 26-59%
- fibroid volume reduction by 40-75% (at the end of 6 months)
- overall complication rate is ~10% with major complications at ~1.5%

ACOG in 2008 issued guidelines that patient with fibroids can be given an option of UAE
NICE(UK): in 2007 recommended UAE with surgery as a first line treatment option

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Chronic Pelvic Pain / Ovarian Vein and Pelvic Varices

Chronic pelvic pain is defined as “non-cyclic” pain lasting greater than six months. A multidisciplinary team approach is needed to treat this often complex medical condition. After a physical examination, a Pap test to rule out cervical cancer, and routine laboratory bloodwork, a cross-sectional imaging study is obtained to be certain that there is not a pelvic tumor. If the clinical symptoms are those of chronic pelvic pain, worse when sitting or standing, and sometimes also associated with varicose veins in the thigh, buttock regions, or vaginal area, the possibility of ovarian vein and pelvic varices must be considered.


Chronic pelvic pain due to ovarian vein and pelvic varices (varicose veins) is treated using nonsurgical, minimally invasive, transcatheter techniques.

The diagnosis of ovarian varices is confirmed by selectively catheterizing specific veins and injecting contrast dye (i.e., performing a venogram). If varices are found on venography, they are embolized with small coils or other agents. The procedure is carried out under local anesthesia with intravenous sedation. Risks are the same for those of any minimally invasive procedure. The blood supply to the varices is blocked by the use of such coils and embolic agents.

A 80% success rate in pain reduction has been reported, (i.e., a reduction in the quantity of pain medications that the woman requires). Pain reduction varies from complete to partial. It is well recognized that varicose veins in the legs cause pain, and therefore it is reasonable that such veins may be a source of chronic pelvic pain if they exist in the pelvis.

Regarding ovarian and pelvic varices, the procedure is generally performed in two stages. The procedure is divided into two segments due to (1) contrast limitations (keeping within the safe limits of dye used for the venogram) and (2) the level of discomfort (pain) experienced by the patient. The second half of the embolization procedure is completed days two weeks later and is generally an out-patient procedure. This gives the woman time to recover in between the two-stage embolization procedure.

The recovery time for women who undergo embolization of ovarian and pelvic varices is similar. Both procedures are generally performed with an overnight admission to the hospital, primarily for pain management during the first 24 hours. After that, the patient is discharged and spends time at home recovering, using oral pain medications for relief of discomfort. Pain is most significant during the first three days after either procedure.


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Veins contain one-way valves that work to allow blood to flow from the testicles and sc***um back to the heart. When these valves fail, the blood pools and enlarges the veins around the testicle in the sc***um to cause a varicocele.

A varicocele is a varicose vein of the testicle and sc***um that may cause pain and lead to testicular atrophy (shrinkage of the testicles).

Open surgical ligation is the most common treatment for symptomatic varicoceles.

Varicocele embolization, a nonsurgical treatment performed by an interventional radiologist, is as effective as surgery with less risk, less pain and less recovery time.


~10% of all men have varicoceles.
Among infertile couples, 30% of men have varicoceles.

The highest occurrence of varicoceles is in men ages 15–35.

80,000–100,000 men in America may undergo surgical correction of varicoceles each year.


* Pain: Men who experience pain in their testicles—particularly when exercising, standing or sitting for a long period of time—may be suffering from varicoceles. Typically, painful varicoceles are prominent in size. If left untreated, varicoceles may lead to infertility.

* Fertility problems: There is an association between varicoceles and infertility. Decreased s***m count, decreased motility of s***m and an increase in the number of deformed s***m are related to varicoceles. Some experts believe these blocked and enlarged veins around the te**es cause infertility by raising the temperature in the sc***um and decreasing s***m production.

*Testicular atrophy: The shrinking of the testicles is another sign of varicoceles. Often, once the testicle is repaired, it will return to normal size.


Varicoceles are fairly simple to detect and diagnose through physical or diagnostic examination.

95 percent of varicoceles are found on the left side of the sc***um. The sc***um looks like a bag of worms. The testicles may be shrunken in size.

If varicoceles are not detectable through the above criteria, abnormal blood flow can often be detected with a noninvasive imaging exam called color flow ultrasound or through a venogram—an X-ray in which a special dye is injected into the veins to "highlight" blood vessel abnormalities.


Both nonsurgical and surgical options available.

Varicocele embolization or catheter-directed embolization:

A nonsurgical treatment performed by an interventional radiologist that is a highly effective, widely available technique to treat symptomatic varicoceles. With this nonsurgical treatment, an interventional radiologist uses catheters and other instruments to shut off blood flow to the dysfunctional vein. Throughout this treatment, the patient is relaxed and free of pain.

Specifically, the interventional radiologist makes a tiny nick in the skin at the groin using local anesthesia, through which a thin catheter (much like a piece of spaghetti) is passed into the femoral vein, directly to the testicular vein. The doctor then injects contrast dye to provide direct visualization of the veins to map out exactly where the problem is and where to embolize, or block, the vein. By using coils or sclerosants (medicine injected into blood vessels to make them shrink), an interventional radiologist blocks the abnormal veins, which reduces pressure on the varicocele. By embolizing the vein, blood flow is redirected through other pathways. Essentially blood flow to the incompetent vein is "shut off" internally without surgery.

Surgical ligation:

One of the most common treatments is open surgical ligation. In this procedure, which is typically performed by a urologist, an incision is made in the skin above the sc***um down to the testicular veins, which are tied off with sutures. Although most patients leave the hospital the same day, 24 percent of surgical ligation patients are required to stay at the hospital overnight.


Patients of open surgical ligation can expect a two- to three-week recovery period. Patients who undergo embolization can return to normal daily activities immediately and without hospital admittance.

Advantages of Catheter-directed Embolization:

+ No surgical incision in scrotal area
+ As effective as surgery, as measured by improvement in semen analysis and pregnancy rates
+ Patients can return to normal daily activities immediately and without hospital admittance; surgery requires several weeks’ recovery and hospital admittance
+ The rare patient who has varicoceles on both sides can have them fixed simultaneously through one vein puncture site; surgery on both sides requires two separate open incisions
+ No general anesthesia required
+ No sutures
+ No infections
+ Cost effective


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Neurofibromatosis (NF) is a group of three conditions in which tumors grow in the nervous system. The three types are neurofibromatosis type 1 (NF1), neurofibromatosis type 2 (NF2), and schwannomatosis. In NF1 symptoms include light brown spots on the skin, freckles in the armpit and groin, small bumps within nerves, and scoliosis. In NF2 there may be hearing loss, cataracts at a young age, balance problems, flesh colored skin flaps, and muscle wasting. The tumors are generally non cancerous.[1]

The cause is a genetic mutation in certain genes. In half of cases these are inherited from a person's parents while in the rest they occur during early development. The tumors involve supporting cells in the nervous system rather than the neurons. In NF1 the tumors are neurofibromas (tumors of the peripheral nerves) while in NF2 and schwannomatosis tumors of Schwann cells are more common. Diagnosis is typically based on the signs and symptoms and occasionally supported by genetic testing.

There is no known prevention or cure. Surgery may be done to remove tumors that are causing problems or have become cancerous. Radiation and chemotherapy may also be used if cancer occurs. A cochlear implant or auditory brainstem implant may help some who have hearing loss.



Urmil Heart And Lung Center, Allayani Wadi, Malifaliya, Near Maskati Hospital


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