Cerebral angiography
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Cerebral angiography | |
---|---|
posterior cerebral circulation. | |
ICD-9-CM | 88.41 |
MeSH | D002533 |
MedlinePlus | 003799 |
Cerebral angiography is a form of angiography which provides images of blood vessels in and around the brain, thereby allowing detection of abnormalities such as arteriovenous malformations and aneurysms.[1] It was pioneered in 1927 by the Portuguese neurologist
Typically a
For some applications[citation needed] cerebral angiography may yield better images than less invasive methods such as computed tomography angiography and magnetic resonance angiography. In addition, cerebral angiography allows certain treatments to be performed immediately, based on its findings. In recent decades, cerebral angiography has so assumed a therapeutic connotation thanks to the elaboration of endovascular therapeutic techniques. Embolization (a minimally invasive surgical technique) over time has played an increasingly significant role in the multimodal treatment of cerebral MAVs, facilitating subsequent microsurgical or radiosurgical treatment.[3][4] Another type of treatment possible by angiography (if the images reveal an aneurysm) is the introduction of metal coils through the catheter already in place and maneuvered to the site of aneurysm; over time these coils encourage formation of connective tissue at the site, strengthening the vessel walls.[5][6]
In some jurisdictions, cerebral angiography is required to confirm brain death.[citation needed]
Prior to the advent of modern neuroimaging techniques such as
Uses
Cerebral angiography is used for diagnosis but may be followed by treatment procedures in the same setting.[8] Cerebral angiography is used to image various intracranial (within the head) or extracranial (outside the head) diseases.[8]
Intracranial diseases are: non-traumatic
Extracranial diseases are:
Although computed tomography angiography (CTA) and Magnetic resonance angiography (MRA) has been used widely in evaluation of intracranial disease, cerebral angiography provides higher resolution on the conditions of blood vessel lumens and vasculature.[10] Cerebral angiography is also the standard of detecting intracranial aneurysm and evaluating the feasibility of endovascular coiling.[11] Performing a cerebral angiogram by gaining access through the femoral artery or radial artery is feasible in order to treat cerebral aneurysms with a number of devices[12]
Certain conditions such as contrast allergy, renal insufficiency, and coagulation disorders are contraindicated in this procedure.[8]
Technique
Before the procedure, focused history and neurological examination is performed, available imaging, and blood parameters are reviewed.
Sedation drug such as
Right common femoral artery (RFA) is the preferred site of access. If RFA access is not optimal, then brachial artery access is chosen. Either a micropuncture system or an 18G access needle can be used with or without ultrasound guidance. There are four types of catheters that can be used: angled vertebral catheter for usual cases, Judkins right coronary catheter (Terumo) for tourtous vessels, Simmons's catheter and Mani's head hunter catheter (Terumo) for extremely tortous vessels. A 5Fr sheath is also placed within and flushed with heparinised saline to prevent clotting around the sheath.[8] In terms of guidewire, Terumo hydrophilic Glidewire 0.035 inches can be used.[8]
To prevent embolism (either due to blood clot or air embolism, "double flush" and "wet connect" techniques are used.[8] In "double flush" technique, a saline syringe is used to aspirate blood from the catheter. Then, a second heparinised saline syringe is used to flush the catheter.[13] "Wet connect" is the technique that connects syringe to a sheath without air bubbles within.[8]
Radiographic views
Cervical arch angiogram is taken if there is any suspicion of
To image the vessels of the neck such as common carotid, internal and external carotid arteries, AP, lateral, and 45 degrees bilateral oblique positions are taken. Contrast injection rate is 3 to 4 ml/sec with total volume of 7 to 9 ml. The frame rate of fluoroscopy is 3 to 4 frames/sec.[8]
To image the anterior cerebral circulation such as internal and external carotid arteries and its branches, AP, Towne's and lateral views are taken.[8] The petrous part of the temporal bone should be superimposed at the mid or lower orbits when taking the AP/Towne's view. Contrast injection rate is 6 to 7 ml/sec with total volume of contrast at 10 ml.[8][9] The frame rate of fluoroscopy is 2 to 4 frames/sec.[8] Neck extension can help to navigate into tortous cerival part of the internal carotid artery.[14][15]
At the level of carotid bifurcation, AP and oblique images are taken. At the cavernous (C4) and ophthalmic segments (C6) of the internal carotid artery, Caldwell and lateral views are taken.[8] At the supraclinoid segment (C5-clinoid, C6-ophthalmic, and C7-bifurcation to posterior communicating artery (PCOM) segments), AP view is used to access the terminal branches such as anterior cerebral artery (ACA), middle cerebral artery (MCA) while oblique view (25 to 35 degrees) is used to access the ACA, anterior communicating artery (ACOM), and MCA bifurcations.[8] Lateral view is useful to visualise the PCOM while submentovertical view is useful to project ACOM above the nasal cavity, thus making it easier to access the anatomy of ACOM. Transorbital oblique view is useful to access the MCA anatomy.[8]
The anatomy of external carotid artery is access via AP and lateral views.[8]
To image the posterior circulation, such as vertebral and basilar arteries, AP, Towne's view, lateral projections near the back of the head and upper part of the neck is taken. In this case, petrous bone should be projected at the bottom or below the orbits to visualise the basilar artery and its branches in AP/Towne's view. The rate of injection is 3 to 5 ml/sec, for a total of 8ml. The fluoroscope will be catching images at a rate of 2 to 4 frames per second.[8] Posterior cerebral artery (PCA) can be seen in AP view.[8] The left vertebral artery is easier to cannulate than the right vertebral because of the straightforward anatomy of the left vertebral artery.[16]
Any activation of primary collateral system (ACOM and PCOM arteries) or secondary collateral system (pial-pial and leptomeningeal-dural) in case of occlusion of internal carotid artery should also be documented.[8][17] Leptomeningeal collaterals or pial collaterals are the small arterial connections that join the terminal branches of ACAs, MCAs, and PCAs on the surface of the brain.[18]
Post-procedural care
Manual compression or percutaneous closure device can be used to stop the bleeding from common femoral artery. Groin
Complications
The most common complication is groin haematoma which occurs in 4% of those affected. Neurologic complications such as transient ischemic attack in 2.5% of the cases. There is also the risk of stroke with permanent neurological defect in 0.1% of the cases and may lead to death in 0.06%.[8] Rarely, 0.3 to 1% of the cases experience cortical blindness from 3 minutes to 12 hours after the procedure. It is a condition where those affected experienced loss of vision with normal pupillary light reflex, and normal extraocular muscles movement. The condition can sometimes be accompanied by headaches, mental state changes, and memory losses.[19]
Some risk factors of complications are if the subject is having
History
In 1896, E. Haschek and O.T. Lindenthal in Vienna, Austria, reported angiography of blood vessels by taking a series of X-rays after injecting a mixture of petroleum, quicklime, and mercuric sulfide into the hand of a cadaver.[1]
Cerebral angiography was first described by Egas Moniz, a Portuguese physician and politician, in 1927. He performed this procedure on six patients. Two developed Horner's syndrome due to leaking of contrast material around the carotid artery, one developed temporary aphasia, and another died due to thromboembolism to the anterior circulation of the brain.[20]
Prior to the 1970s the typical technique involved a needle puncture directly into the carotid artery,
References
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