- •Foreword
- •Preface
- •Glossary
- •1. Introduction
- •2. Historical Considerations
- •2.1 Arteriovenous Fistula and Pulsating Exophthalmos
- •2.2 Angiography
- •2.3 Therapeutic Measures
- •2.4 Embolization
- •References
- •3.1 Osseous Anatomy
- •3.1.1 Orbit
- •3.2 Anatomy of the Dura Mater and the Cranial Nerves
- •3.2.1 Autonomic Nervous System
- •3.3 Vascular Anatomy
- •3.3.1 Arterial Anatomy
- •3.3.1.1 Internal Carotid Artery
- •Meningohypophyseal Trunk (MHT)
- •Ophthalmic Artery
- •Ethmoidal Arteries
- •3.3.1.2 External Carotid Artery
- •3.3.1.2.1 Ascending Pharyngeal Artery
- •3.3.1.2.2 Internal Maxillary Artery
- •3.3.1.2.3 Middle Meningeal Artery
- •3.3.1.2.4 Accessory Meningeal Artery
- •3.3.2 Venous Anatomy
- •3.3.2.1.1 Embryology
- •3.3.2.1.2 Anatomy and Topography
- •Orbital Veins
- •Superior Ophthalmic Vein
- •Inferior Ophthalmic Vein
- •Central Retinal Vein (No Direct CS Tributary)
- •Uncal Vein, Uncinate Vein
- •Sphenoparietal sinus (Breschet), Sinus alae parvae, Sinus sphenoidales superior (Sir C. Bell)
- •Intercavernous Sinus, Sinus intercavernosus, Sinus circularis (Ridley), Sinus ellipticus, Sinus coronarius, Sinus clinoideus (Sir C. Bell), Sinus transversus sellae equinae (Haller)
- •Meningeal Veins
- •Veins of the Foramen Rotundum, Emissary Vein
- •Inferior Petrosal Sinus, Sinus petrosus profundus, Sinus petro-occipitalis superior (Trolard)
- •Venous Plexus of the Hypoglossal Canal, Anterior Condylar Vein
- •Posterior Condylar Vein
- •Lateral Condylar Vein
- •Inferior Petroclival Vein
- •Petro-occipital Sinus, Sinus petro-occipitalis inferior, petro-occipital vein (Padget)
- •Transverse Occipital Sinus (Doyen)
- •Basilar Plexus (Virchow)
- •Marginal Sinus
- •Foramen Ovale Plexus (Trigeminal Sinus), Sphenoid Emissary, “Rete” of the Foramen Ovale
- •Vein of the Sphenoid Foramen (Foramen Venosum, Foramen of Vesalius)
- •Foramen Lacerum Plexus
- •Pterygoid Plexus
- •3.3.2.4 Other Veins of Importance for the CS Drainage or for Transvenous Access to the CS
- •Facial Vein
- •Frontal Vein
- •Angular Vein
- •Middle Temporal Vein
- •Internal Jugular Vein
- •The External Jugular Vein
- •Vertebral Vein, Vertebral Artery Venous Plexus
- •Deep Cervical Vein
- •References
- •Introduction
- •4.1.1 Dural Arteriovenous Fistulas (DAVFs)
- •4.1.2 Cavernous Sinus Fistulas (CSFs)
- •References
- •Introduction
- •5.1 Etiology and Pathogenesis of Type A Fistulas
- •5.2 Etiology and Pathogenesis of Type B–D Fistulas
- •5.2.1 Pregnancy
- •5.2.2 Hormonal Factors
- •5.2.3 Thrombosis
- •5.2.4 Venous Hypertension
- •5.2.5 Trauma
- •5.2.6 Embolization
- •5.2.7 Congenital
- •5.2.8 Other Potential Factors
- •5.2.9 Various
- •5.3 Prevalence
- •5.3.1 Natural History
- •References
- •Introduction
- •6.1 Extraorbital Ocular Symptoms
- •6.1.1 Orbital Pain
- •6.2 Orbital Symptoms
- •6.2.1 Exophthalmos
- •6.2.2 Conjunctival Engorgement and Chemosis
- •6.2.2.1 Retinal Hemorrhage
- •6.2.3 Corneal Damage
- •6.2.4 Orbital Bruit
- •6.2.6 Secondary Glaucoma and Visual Loss
- •6.3 Other and Neurological Symptoms
- •References
- •7. Radiological Diagnosis of DCSFs
- •7.1 Non-invasive Imaging Techniques
- •7.1.2 Doppler and Carotid Duplex Sonography
- •7.2 Intra-arterial Digital Subtraction Angiography (DSA)
- •7.2.1 Introduction
- •7.2.2 Technique
- •7.2.3 Angiographic Protocol for DCSFs
- •7.2.4 Angiographic Anatomy of the Cavernous Sinus
- •7.2.5 Flat Detector Technology in Neuroangiography
- •7.2.6 Rotational Angiography and 3D-DSA
- •7.2.6.1 Dual Volume Technique (DVT)
- •7.2.6.2 Angiographic Computed Tomography (ACT), DynaCT (Siemens), C-arm Flat Detector CT (FD-CT), Flat Panel CT (FP-CT) or Cone Beam CT
- •7.2.6.3 Image Post-Processing
- •7.2.6.4 3D Studies of the Cavernous Sinus Region
- •References
- •8. Endovascular Treatment
- •8.1 Techniques of Transvenous Catheterization
- •8.1.1 Inferior Petrosal Sinus Approach
- •8.1.2 Alternative Approaches to the Cavernous Sinus
- •8.1.3 Other Techniques
- •8.2 Embolic Agents
- •8.2.1 Polyvinyl Alcohol (PVA) and Embospheres
- •8.2.2 Stainless Steel Coils
- •8.2.5 Stents
- •8.3.1 Approaches (Benndorf et al. 2004)
- •8.3.2 Angiographic and Clinical Outcome
- •8.4 Discussion of Transvenous Occlusions
- •8.4.1 Approaches
- •8.4.1.1 IPS Approaches
- •8.4.1.6 Transfemoral Pterygoid Plexus Approach (PP Approach)
- •8.4.1.7 Transfemoral Cortical Vein Approach
- •8.4.1.10 Direct Puncture of the Foramen Ovale
- •8.4.2 Embolic Materials
- •8.4.2.1 Particles
- •8.4.2.2 Coils
- •HydroCoils (Hydrogel)
- •8.4.2.4 Ethylene-Vinyl Alcohol Copolymer (OnyxTM)
- •8.4.2.5 Stents and Covered Stents
- •8.4.3 Anatomic Results, Clinical Outcome and Complications of Transvenous Occlusions and Transarterial Embolizations
- •8.5 Conclusion
- •References
- •9. Alternative Treatment Options
- •9.1 Spontaneous Thrombosis
- •9.2 Manual Compression Therapy
- •9.4 Radiotherapy
- •9.5 Surgery
- •References
- •10. Hemodynamic Aspects of DCSFs
- •10.1 Introduction
- •10.2 Basic Hemodynamic Principles
- •10.3 Invasive Assessment of Hemodynamics
- •10.4 Flow Velocity and Pressure Measurements in Brain AVMs and DAVFs
- •10.5 Hemodynamics and Pathophysiology in CSFs
- •Comments
- •References
- •11. Summary
- •Subject Index
Subject Index
A
accessory meningeal artery (AMA) 30 acetazolamide 91
ACT, see angiographic computed tomography acute respiratory distress syndrome 259 alopecia 286
aneurysm 3, 6, 146
–intraorbital 4
–of the ophthalmic artery 6 angiogenesis 70
angiographic computed tomography (ACT) 142, 143, 146, 310
angiography 6
–iodine-enhanced 8
–spontaneous occlusion 78
–three-dimensional 148
angiotomography 139 angular vein 44 anisocoria 59 annulus of Zinn 21, 37 anterior
–condylar confluens (ACC) 33, 46
–condylar vein 42
–condyloid foramen 46
–ethmoidal foramen 28
–ramus 25
antiplatelet therapy 207
Arteria canalis pterygoidei Vidii 29 Arteriae anastomoticae 30
arterial
–embolization 9
–pressure 297 arterialized sinus 297 arteriography 283 arteriolar neoformation 69 arteriosclerosis 6, 68 arteriovenous
–fistula 3
–malformation 293
–shunt (AV shunt) 1, 58, 60, 62, 69, 72, 109, 134, 158, 207, 232, 266, 297
–– blood flow 293
–– indirect 54
–– lesions 85
artery of the orbital fissure 163 ascending pharyngeal artery (APA) 29 aspirin 259
autonomic nervous system 21
AV shunt, see arteriovenous shunt
B
balloon
–detachment 156, 237
–occlusion 229
Barrow’s classification 58
basic fibroblast growth factor (bFGF) 74 basilar plexus 42
benign fistula 79 Bernoulli’s equation 294 bilateral fluoroscopy 231 bi-plane
–fluoroscopy 251
–road mapping 225, 237
blank road mapping 193, 198, 209, 231 blepharoptosis 235, 236, 260
blood
–flow 294
–viscosity 294 Breschet’ sinus 38 bruit 85, 90
C
canal of Arnold 18 canaliculus innominatus 18 canthotomy 91
314 Subject Index
capillary shunting 300 caroticoclinoid foramen 16 carotid
–artery 6
–cavernous fistula (CCF) 4, 9, 35, 156
–– spontaneous thrombosis 9
–ligation 237
–occlusion 67
–siphon 23
–– stenosis 110
catheterization 191 cavern 309
cavernous aneurysm 67, 87 cavernous arteriovenous shunt 310 cavernous sinus 1, 25
–anatomy 15, 32, 152
–angiographic anatomy 111
–drainage 40
–fistula (CSF)
–– Barrow’s classification 56
–– classification 51, 54, 57
–– etiologic classification 60
–– hemodynamic classification 60
–– pregnancy 68
–– surgery 287
–– type A 55
–– type B 55
–intractable fistula 286
–sinography 229
–thrombosis 34, 231
cavernous structure 34
CCF, see carotid cavernous fistula central retinal vein (CRV) 38
cerebral angiography 109, 139, 278, 310 cerebrovascular disease 190, 253 cesium iodide scintillator 139
chemosis 59, 85, 87, 88, 131, 133, 209, 225, 261, 284, 304 choroidal effusion 280
circle
–of Haller 27
–of Willis 23, 61
–of Zinn 27 clopidogrel 259
Cognard’s classification 77 coil 252
–deployment 193
color-Doppler ultrasound 107 computed tomography (CT) 97, 109
–cone beam 144
–multi-slice scanner 142
–serial-enhanced (DE-CT) 97 cone beam
–algorithm 146
–computed tomography 144 conjunctival
–chemosis 89
–engorgement 88
conjunctivitis 88, 303 controlled hypotension 282, 310 Copper wire 253
cornea
–damage 89
–dehydration 89
–trophic damages 89
coronary flow reserve (CFR) 295 cortical
–drainage 51, 53, 99, 195, 282
–reflux 59, 78
corticosteroid 208, 261 covered stent 207, 259 cranial nerve
–anatomy 20
–deficit 87
–palsy 261
craniotomy 225, 251, 260 Crutchfield clamp 67
CSF, see cavernous sinus fistula CT, see computed tomography Cushing’s disease 229, 230 cyanoacrylate 204
D
Dacron fiber 198 Dandy’s triad 85
dangerous anastomosis 25, 111, 258 DAVF, see dural arteriovenous fistula DCSF, see dural cavernous sinus fistula deep cervical vein 45
detachable coil 199, 234, 235, 254 diabetes insipidus 261, 266 diaphragm sella 20
digital subtracted angiography (DSA) 7, 156
–intra-arterial 109
–three-dimensional 1 dilatation 300
dimethyl sulphoxide (DMSO) 205
diplopia 59, 133, 209, 212, 215, 220, 261, 278, 284, 309 Dorello’s canal 41, 231
DSA, see digital subtracted angiography dual volume technique (DVT) 143, 145 duplex carotid sonography (DCS) 62, 108 dura mater 32
–anatomy 20
dural arteriovenous fistula (DAVF) 51
–anatomic classification 51, 52
–prevalence 76
dural carotid-cavernous fistula 258
dural cavernous sinus fistula (DCSF) 1, 73
–angiographic protocol 110
–classification 57
–drainage 85, 122
–embolization 73
Subject Index 315
–etiology 65
–late restrictive type 59
–natural history 65, 78
–neuro-ophthalmology 85
–prevalence 65, 76
–proliferative type 59
–radiological diagnosis 97
–restrictive type 59
–thrombosis 69
–trauma 72
–type A
–– etiology 66
–– pathogenesis 66
–type B 55
–– etiology 67
–– pathogenesis 67
DynaCT 144–146, 150, 163, 179 dysarthria 259
dysesthesia 86, 235
E
ECA, see external carotid artery Ehlers-Danlos syndrome 54 electrocoagulation 11 electrothrombosis 199, 253, 254 embolic
–agent 252
–plug 257
embolization 10, 228, 289 Embosphere 196–198 emissary vein 40 endocrine
–ophthalmopathy 303
–orbitopathy 209 endogenous estrogen 68 epidural shunt 54 epistaxis 86
esmolol 282 estrogen 68 ethmoidal artery 28
ethylene-vinyl alcohol copolymer (Onyx) 205, 257 exophthalmos 59, 66, 85, 87, 88, 97, 98, 104, 131, 133, 215,
220, 233, 261, 284, 304 external
–carotid artery (ECA) 29
–jugular vein 45
extracranial duplex sonography 303
extradural neural axis compartment (EDNAC) 35 extraorbital ocular symptom 86
F
facial nerve palsy 258, 267 facial vein 35, 44
familial thrombophilia 71
fan beam geometry 146
fast imaging with steady state precession (FISP) 102 fibromuscular dysplasia 54, 110
film tomography 6 fistula
–drainage 122
–occlusion 278
–steal 61
flat detector 139, 140, 143 flow velocity 297 FloWire system 295
fluorescein angiography 300 fluoroscopy 193, 198, 237 foramen
–lacerum 16, 23, 30
–– plexus 43, 171
–– recurrent artery 26
–of Henle 16
–of Hyrtl 28
–of the ophthalmomeningeal vein 18
–of Vesalius 30
–ovale 16, 38
–– direct puncture 237
–– plexus 43, 171
–rotundum 16, 30, 40, 142, 158
–spinosum 16
–transversarium 45
–venosum 16, 35, 43
–Vesalii 16
fractional flow reserve 295 frontal vein 4
G
galvanopuncture 253
gamma knife radiosurgery 284, 285 Gasserian ganglion 21, 23
genetic thrombophilic abnormality 71 Gianturco coil 198, 253
Giuglielmi detachable coil 199 glaucoma 91, 297
glubran 256
Goldmann tonometer 91 gonioplasty 91
Gruber’s ligament 21 guidewire 193
H
Hagen-Poiseuille’s law 294 head injury/trauma 66, 73 hematotachography (HTG) 108 hemianopia 265
hemiparesis 251, 265, 287 hemiplegia 260
316 Subject Index
hemodynamic
–dysregulation 85
–invasive assessment 295
–principles 294
heparin 78 heparinization 196, 254
Hertel exophthalmometer 88 high-flow fistula 62 Histoacryl 204, 256 histography 148
HydroCoil 202, 203, 242, 255, 264 hydrogel 202, 255
hydrophilic microsphere 197 HyperSoft coil 243 hypophysectomy 73 hypotension 297 hypothermia 284
– hemorrhage 235, 236, 264 intrasinus pressure 304 ischemia 70, 72, 258
J
jugular foramen 18
K
keratopathy 89
knee of the carotid 23 Kuru Kuru technique 231
L
I |
lagophthalmos 89 |
|
|
||
ICA, see internal carotid artery |
lamina cribrosa 38 |
|
Latanoprost 277 |
||
idiopathic trigeminal neuralgia 86 |
||
Lateral |
||
IMA, see internal maxillary artery |
||
– clival artery 24 |
||
image |
||
– condylar vein 42 |
||
– intensifier 140 |
||
laterocavernous sinus 35, 39 |
||
– postprocessing 146 |
||
leak balloon microcatheter 11 |
||
incisura supraorbitalis 44 |
||
leptomeningeal |
||
infarction 261 |
||
– drainage 51, 66, 106, 251, 304 |
||
inferior |
||
– reflux 78 |
||
– bulb 45 |
||
Lipiodol 266 |
||
– hypophyseal artery 24 |
||
liquid embolic agent 204 |
||
– ophthalmic vein (IOV) 37 |
||
loop technique 193 |
||
– oribtal fissure (IOF) 18 |
||
low-contrast imaging 146 |
||
– petroclival vein (IPCV) 41, 42, 171 |
||
low-flow shunt 300 |
||
– petro-occipital vein 179 |
||
|
||
– petrosal sinus (IPS) 31, 40, 191, 208 |
|
|
inferolateral trunk (ILT) 21, 24 |
M |
|
infraclinoid aneurysm 66 |
||
intercavernous sinus (ICS) 35, 39 |
|
|
interclinoid foramen 16 |
magnetic resonance imaging (MRI) 97 |
|
internal |
magnetization-prepared rapid gradient echo sequence |
|
– carotid artery (ICA) 15, 21 |
(MP-RAGE) 105 |
|
– – venous plexus 43, 171 |
magnification angiography 139 |
|
– jugular vein (IJV) 22, 44 |
manual compression therapy 280 |
|
– maxillary artery (IMA) 29 |
marginal |
|
intimal hyperplasia 260, 285 |
– sinus 42 |
|
intracavernous |
– tentorial artery 24 |
|
– aneurysm 67 |
maximum intensity projection (MIP) 142, 148, 149 |
|
– stenosis 257 |
meningeal vein 31, 38, 40 |
|
intracerebral hemorrhage 86, 196 |
meningeoma 91, 199 |
|
intracranial |
meningitis 87 |
|
– aneurysm 87 |
meningohypophyseal trunk (MHT) 21, 23 |
|
– hemorrhage 53, 78, 231, 262, 264, 286 |
menopause 68, 75, 76 |
|
– neoplasm 87 |
microaneurysm 300 |
|
intraorbital |
microcatheter 111, 158, 191, 193, 197, 229 |
|
– aneurysm 4, 65 |
– wedged position 256 |
|
|
|
Subject Index 317
microguidewire 193
–with hydrophilic coating 190 microneurosurgery 58 micropuncture 197 microtrauma 66
middle meningeal artery (MMA) 30 middle temporal vein 44 morphometer 139
MRI, see magnetic resonance imaging multiplanar
–cross sectional image 167
–reformatting (MPR) 146
N
nasal arch 44
NBCA, see N-butyl-2-cyanoacrtylate N-butyl-2-cyanoacrtylate (NBCA) 204, 256
– polymerization 204 nerve palsy 260 neuralgia 86 neuroangiography 139 neuro-ophthalmology 85 nitroglycerine 282 nitroprussiate 282
non-detachable pushable microcoil 198 non-dural arteriovenous fistula 71 non-pulsating exophthalmos 8, 67 nylon balloon catheter 11
O
obstruction 233 occlusion 51, 72 occulomotor foramen 21
Onyx 205, 246, 251, 255, 310 ophthalmic
–artery (OA) 26
–sinus 37
ophthalmoplegia 10, 59, 87, 99, 215 optic
–canal 18, 19
–disc 27
–nerve 26, 37 orbital
–bruit 90
–ecchymosis 261
–pain 86
–phlebography 36
–tumor 309
–vein 7, 36 orbitopathy 209 osseous anatomy 15, 17 osteography 142 osteophyte 142
P
palpebral silk granuloma 260 periorbital cephalgia 86 perivenous leakage 300 petroclival fissure 228 petro-occipital sinus 42 petrosal sinus 289
petrous apex 22, 32 phlebography 41, 124, 191
–three-dimensional 163, 167, 179 phlebothrombosis 69
phlegmon 309
PION, see posterior ischemic optic neuropathy pituitary
–adenoma 73, 229
–fossa 39
platinum
–coil 204, 255
–detachable coil 200
–pushable microcoil 198 pneumotonometer 91
polyglycolic-polyactic biopolymer (PGLA) 202 polymer 191
polytetrafluoroethylene (PTFE) 207 polyvinyl alcohol (PVA) 197 posterior
–condylar vein 42
–ischemic optic neuropathy (PION) 92
–ramus 26
pregnancy 68 PressureWire 295 propofol 282, 284
proptosis 10, 90, 97, 209, 212 prothrombin gene mutation 71
pseudoaneurysm after balloon detachment 156 pterygoid
–canal 29
–plexus 43 ptosis 59, 215 puerperium 76
pulsatility index 297
pulsating exophthalmos 4, 6, 65, 280, 304
–history 3
pulse-synchronous pulsation
–of the bulb 91
–of the eyelid 91
R
radiosurgery 58, 285, 310 radiotherapy 284
ramus
–caroticus 29
–jugularis 29
reactive wall hypertrophy 233
318 Subject Index
recanalization of thrombosed sinus compartments 309 recurrent artery of the foramen lacerum (RAFL) 26 red exe shunt syndrome 278
reflux-hold reinjection 257 Rektorzik’s plexus 171, 179 retinal
–artery occlusion 233
–hemorrhage 89
–vein occlusion 282, 286 retrobulbur puncture 236 retrograde catheterization 297 revascularization 72 Reynolds number 294 rhizotomy 72
rotating C-arm 143, 144 rotational
–osteography 142
–venography 179
S
Seldinger’s technique 109 sella turcica 15, 26, 237 septoplasty 73, 74 sigmoid sinus 36
silicon vascular loop 197 sinus
–ophthalmicus 37
–stenosis 71
–thrombosis 71, 179 SmartMap 295 SmartWire 295
sodium nitroprussiate 282 SOF, see superior orbital fissure soft coil 264
Sonic catheter 259
SOV, see superior ophthalmic vein sphenobasal sinus 39 sphenopalatine foramen 29
sphenoparietal sinus (SPPS) 31, 33, 38, 39 spin echo sequence 99
spontaneous thrombosis 277 stainless steel coil 198
steal phenomenon 293, 297 stent 206, 207, 259 sternocleidomastoid muscle 280 stretch resistant coil 201
stroke 110, 257, 264, 265 subarachnoid hemorrhage 146, 229 subtraction angiography 6
superficial middle cerebral vein (SMCV) 31, 38 superior
–ophthalmic vein (SOV) 36, 196, 208, 232
–– catheterization 220
–– transcutaneous approach 235
–orbital fissure (SOF) 18, 19
–petrosal sinus (SPS) 31, 40
–ramus 25
superior orbital fissure (SOF) 237 Sylvian vein 33, 226, 251, 264
– puncture 225
T
TAE, see transarterial embolization tarsorrhaphy 90
Terumo guidewire 193, 234 Thorotrast 109 thrombogenic coil 289 thrombophlebitis 69
thrombosis 69, 78, 99, 127, 196, 229 thrombus 73
tinnitus 225 tissue hypoxia 72
Tolosa-Hunt syndrome 87, 99 Tracker-18 microcatheter 229 transarterial
–balloon occlusion 254
–coil embolization 199
–embolization (TAE) 58, 252, 265, 278, 287, 289 transcranial Doppler ultrasound 303 transcutaneous puncture 236
transfemoral
–catheterization 234
–cortical vein 234
–embolization 282
–facial vein 232
–pterygoid plexus 234
–superior petrosal sinus 234
transient facial edema 265 transophthalmic ultrasound 303 transvenous
–catheterization 73, 189, 190
–embolization 122, 20,8 260, 289
–occlusion (TVO) 11, 211, 213, 217, 264
–phlebogram 124
transverse sinus 39, 42 trauma 65
traumatic carotico-cavernous fistula 7 true anatomica compartmentalization 232 Trufill 256
truncus carotico-cavernosus lateralis 26 Tungsten 266
– coil 255
TVO, see transvenous occlusion
U
UltraSoft coil 201 ultrasonography 106 uncal vein 39
Subject Index 319
uncinate vein 39 urapidil 282
V
vascular
–anatomy 21
–– of the head and neck area 5
–endothelial growth factor (VEGF) 74 vein
–of Labbé 234
–of Rosenthal 38, 39, 54
–– leptomeningeal drainage 8
–of the sphenoid foramen 43 venography 163
–three-dimensional 179
venous
–anatomy 31
–cavern 35
–congestion 261
–cortical hypertension 255
–dilatation 300
–disease 76
–drainage 53, 58, 105, 281
–flow velocity 300
–hypertension 70, 72, 309, 311
–ischemia 78
–outflow obstruction 70
–outflow restriction 311
–perforation 261
–plexus 34
–– of Rektorzik 46
–– of the hypoglossal canal 42
–pressure 280
–stenosis 51
–thrombosis 75, 85, 258 vertebral
–artery venous plexus 45
–vein 45
vidian artery 29
visual loss 91, 233, 260, 304
volume rendering technique 148, 149 VortX coil 198, 220
V-Trak system 202, 203
W
white eyed cavernous shunt 92, 93, 99, 309
X
X-ray 6, 139, 156
