 Good morning everyone. I am Dr. Gurudev Singh Saini from Vardaman Mahavir Mediol's College at Subjain Hospital. I am presenting my paper on the role of image-guided pertinent sclerotherapy in management of slow-flow vascular malformation and its MRI correlation. To evaluate the role of MR imaging and response evaluation after completion of image-guided sclerotherapy, to evaluate symptomatic relief, In introduction, slow-flow vascular malformations are congenital anomalies that usually appear at birth. They are irregular, variably-directed, dysmorphic channels, having thin basement membrane and flattened endothelium in contrast to hyposimilarities seen in vascular tumors. They can be diffused, localized, superficial or deep. Slow-flow vascular malformations can be of three types, venous, lymphatic and capillary. Venous malformation clinically presents in different ways from a small, vague blue patch on skin to a soft, compressible, non-posseltile mass. Among superficial reasons, 40% are found in head and neck region, 20% in trunk and 40% in extremities. They can also be found in viscera. The most common manifestations are pain, bleeding, compression of adjacent structures, ulceration and cosmetic deformity. They generally expand after the valve salva maneuver and flatten with applied pressure. Diagnosis is typically based on history, clinical presentation, valuation with Doppler, ultrasound and conformation by MR imaging. Particular drainage flow therapy is best treatment because it is a simple, safe and effective method. Commonly used kilosynes are 3% sodium tetradical sulfate, sodium moruate, 3% polydocanol, bluomycin, absolute ethanol, doxycycline and hypotonic saline solution. Methods A CAHOT observation study of 35 patients was done in Department of Racial Diagnosis, BMMC and Surgeoning Hospital, New Delhi. After inbound written consent, history, local examination and ultrasound examination, MRI was done, MRI protocol, 3mm sections were taken as follows. That saturated T2 weighted stir images in axial and coronal slash sagittal planes. T1 weighted FSC images in axial and coronal slash sagittal planes in pre and post condom, trast phase. Mean diameter of lesion in two planes was calculated. Lesions were divided based on size as follows. Grade 1 well defined less than 5 centimeter diameter. Grade 2 well defined more than 5 centimeter diameter. Grade 2B well defined less than 5 centimeter diameter. Grade 3 well defined more than 5 centimeter diameter. Sclerotherapy treatment was done under ultrasound and fluoroscopic guidance with local anesthesia and aseptic precaution as an OPD procedure. After four sessions or after complete thrombosis of lesion as seen on ultrasound, MRI was done after 30 days of last session. Mean diameter of lesion in two planes was calculated and reduction in size of lesion was evaluated and classified into five groups as below. One was, lesion is large and full of skin. Two, no change. Minor improvement, less than 50% decrease in size. Marred improvement, more than 50% decrease in size. Five, cured. Lesion no longer visible on MRI. Assessment of patient's symptom at relief according to Likert scale as shown below. Score, seven. Description, very good. Percentage and change, more than 75% improvement. Six, good. More than 50% improvement. Five, fairly good. More than 25% improvement. Four, same as before. Zero, improvement. Three, fairly bad. More than 25% deterioration. Two, bad. More than 50% deterioration. One, very bad. 70% deterioration. Any side effect of treatment like nausea, vomiting, infection, skin discoloration, when injected side, ulceration, peripheral nerve injury, and venous thromboembolism was reported. Study flow chart. The patient who was suspected to have vascular malformation was taken into a study. Physiology and proper clinical examination was done. A pre-treatment MRI was performed following which image-guided perturian sclerotherapy. Follow-up and subscription session was done if required. Follow-up MRI was done after four peaks of last session. Results, out of 35 patients who were included in this study, 45.7% of the patient had MRI size category one. 25.7% of the patient had MRI size category two A. 14.3% of the patient had MRI size category two B. 14.3% of the patient had MRI size category three. All the patient, 94.3% of the patient, sodium trititechyl sulfate was used as close end and 5.7% of the patient on them, polytopinol was used. No change in size of lesion was seen in 25, 20% cases. My improvement in 40% cases. Based on reduction in size as evaluated on MRI. No patient had increase in size of lesion and no one showed complete obliteration. The main percentage reduction of size was 34.23%. Symptomatic improvement in 8.6% patient was same as before. 48.6% patient had fairly good improvement. 37.1% had good improvement and 5.7% patient had very good improvement. Most common complication was pain followed by edema. Other complications were hyperpigmentation, scarring, mouth ulcers. Case one, 22 year female with swelling on left side of neck for two years with on and off pain. On examination there was ill-defined swelling. No skin discoloration, visual pulsation of groove. Figure one I showed ultrasound imaging showing patent anical channels and this image shows sclerosis injected on the fluoroscopic guidance. Figure one C and one D shows pre-sclerotherapy MRI, coronal and axial scleromy respectively showing a lesion here and on post-sclerotherapy and the lesion showed decrease in size. Case two, 30 year old male with swelling on left little aspect of neck for 10 years. No history of trauma, no skin discoloration, visual pulsation of groove. Sclerosant injected on the fluoroscopic guidance I shown in this figure and after ultrasound these are the thrombosis channels of sclerotherapy and plebulitis vision. Figure two C and two D shows axial and coronal steric images of lesion as shown here and after sclerotherapy there is reduction in size of this lesion. Case three, 14 year old male with swelling on right cheek for two years. On examination there was ill-defined swelling. No skin discoloration, visual pulsation of groove. Figure three and three B are pre-sclerotherapy images axial and steric. This is the lesion and after sclerotherapy there is reduction in size of this lesion. Discussion, various malformation management and treatment requires a multi-disciplinary approach that involves specialist in radiology, interventional radiology, surgery and primary physician care. We found that image-guided pre-sclerotherapy is an effective, safe and inexpensive method for treating slow flow venous malformations. In most previous studies a reduction of at least 50% defined as a good to excellent result and we used the same threshold. In our study 40% patients shown more than 50% reduction in size as seen on MRI. Sodium tetradactyl sulfate and polydacona are effective sclerizing agents. In this study significant symptomatic relief was observed with this treatment considering the side effects and results of this treatment. It is safe to say that sclerotherapy should be first-line treatment for various vascular malformation before proceeding to surgery. MRI is also expensive that it is best modality to compare the results of sclerotherapy treatment. However, clinical comparison based on patient and clinicians' analysis cannot be undermined. These are my references. Thank you.