Cerebrovascular Angiography & Intervention

Cerebrovascular Angiography & Intervention Procedures

• This presentation covers cerebrovascular angiography and intervention procedures.

Objectives

• Describe the major vessels within the intracranial vascular anatomy.
• List and describe various diagnostic and interventional procedures for the vascular anatomy of the brain and neck.
• Identify indications and contraindications for angiography in specific areas.
• Describe vessel access techniques for angiography.
• List patient positions, projections, and views used during diagnostic cerebral angiography.
• Identify contrast agents, total amounts, and injection rates for cerebral angiography procedures.
• List the equipment and materials such as catheters and guidewires required for cerebral angiography.
• Identify common complications associated with cerebral angiography.
• Recognize cerebral vascular anatomy and pathologies on cerebral angiograms.

Aortic Arch, Neck and Brain Vascular Anatomy Review

Arteries:

• Aortic Arch: Origin of arteries supplying the heart, neck, and head.
• Brachiocephalic: Vessel that bifurcates into the right subclavian artery and the right common carotid artery.
• Common Carotid (R & L): Supplies blood to the brain and bifurcates at the C4 level.
• Subclavian (R & L): Origin of the right and left vertebral arteries as they branch off their respective subclavian arteries.
• Internal Carotids (R & L): Supplies blood to cerebral hemispheres, pituitary gland, orbital structures, and the anterior part of the brain.
• External Carotids (R & L): Supplies blood to the anterior neck, face, scalp meninges, facial, maxillary, temporal, and occipital regions.
• Carotid Siphon: A notable section of the internal carotid artery just before it bifurcates into the anterior and middle cerebral arteries, and it is critical for pathology assessment.
• Anterior Cerebral: Located in the forebrain midline, curves around the corpus collosum, with several branches.
• Middle Cerebral: Supplies lateral aspects of the anterior circulation, providing deep brain tissue with blood.
• Vertebral (R & L): Arises from subclavian arteries, passes through C6-C1 transverse processes, supplies posterior brain, and unites to form the basilar artery.
• Basilar: Rests on clivus of sphenoid bone and bifurcates into right and left posterior cerebral arteries.
• Posterior Cerebral (R & L): Supplies posterior part of the brain and cerebellum.
• Anterior Communicating: Connects the two anterior cerebral arteries midline.
• Posterior Communicating: Branches off internal carotid artery before bifurcation and connects to the posterior cerebral artery.

Veins:

• Dural Venous sinuses: Venous drainages located between the inner and outer layers of the dura mater.
• Superior Sagittal Sinus: Located in the superior border of the falx cerebri.
• Inferior Sagittal Sinus: Located in the inferior margin of the falx cerebri.
• Straight Sinus: Formed where the falx cerebri meets the tentorium cerebelli and continues as a continuation of the inferior sagittal sinus.
• Transverse (R & L): Also known as lateral sinuses, found along the lateral aspect of the tentorium cerebelli.
• Sigmoid Sinus: Transverse sinuses turn medially and inferiorly to become sigmoid sinuses at the level of the temporal bones' petrous parts.
• Galen: Continues under the corpus callosum to form the internal cerebral vein.
• Occipital Sinus: The smallest of the dural venous sinuses, and runs along the occipital bone's inner surface.
• Confluence of Sinuses: Also referred to as the Torcular Herophili, is the intersection of the superior sagittal sinus, straight sinus, occipital sinus, and two transverse sinuses.
• Internal Jugular Vein (R & L): Extends from the skull base to the sternal end of the clavicle
• External Jugular Vein (R & L): Drains outer structures of the head and drains into the subclavian vein.
• Vertebral (R & L): Formed by uniting internal vertebral venous plexuses, drains each vertebral artery's venous plexus, and empties into brachiocephalic veins.
• Subclavian (R & L): Continuation of the axillary vein, located underneath the clavicle, connects with the jugular.
• Brachiocephalic (R & L): Joins the SVC with the jugular to drain blood directly into the left atrium of the heart.
• SVC: Large diameter vein located in the anterior right superior mediastinum and drains into the right atrium.

Cerebral Angiogram

• Declined as a primary diagnostic tool but remains important for intervention, presurgical mapping, and pre-cancer treatment.
• CT and MRI are the preferred choices for examining brain pathologies. Intracranial saccular aneurysms and carotid artery disease in the neck are found by these methods.
• Cerebral circulation time is 3-5 seconds from the internal carotid artery to the jugular vein

Indications

• Interventional & pre-surgical mapping
• Differential diagnosis
• Aneurysms/Pseudoaneurysms
• Atherosclerotic disease
• trauma
• CVA

Contraindications

• CM sensitivity
• Severe Hypertension
• Advanced Arteriosclerosis
• Extremely ill or comatose patients
• Severe subarachnoid on intracerebral hemorrhaging

Complications

• Contrast agent reactions
• Mechanical injuries
• Physiologic complications

Cerebral Arteriograms Done

• Non-selective arteriogram: 4 vessel flush
• Selective arteriograms to view a cerebral anterior circulation
• Selective Arteriograms to see a cerebral posterior circulation

Injection Rates, Guidewire & Catheter

• Aortic Arch requires a flow rate of 22ml/s
• Common Carotid A requires a flow rate of 7ml/s
• Internal Carotid A requires a flow rate of 6ml/s
• External Carotid A requires a flow rate of 3ml/s
• Vertebral A requires a flow rate of 5ml/s
• Use a 5F Introducer Sheath which is 10-3cm long
• Use a J-Wire, 0.035mm, 180cm long

Cerebral Circulation Time

• Blood takes 3-5 seconds from ICA to Jugular V without contrast media.
• 4.13 seconds from siphon region to parietal veins with a maximum concentration of CM.
• Pathologic conditions:
  • AVMs shortens the time
  • Arterial Vasospasm: Lengthens the time

Aortic Arch and 4 Vessel Flush Angiograms

• Aortic Arch Open w/ a 35 degree RPO or LAO projection based on Merrill's
• Aortic Arch Superimposed on itself (Lateral Projection w/ RAO 35-45 degrees
• The inferior margin of the mandible is superimposed onto the occiput.
• Equipment needed; biplane, automatic injector, and a DSA
• CM Injection Rate: 22 milliliters/second, 45 total ML
• Catheter: 5 French pigtail; 100 cm length
• Vessels Demonstrated: Aortic Arch, Brachiocephalic, Rt. & Lt Subclavians and left vertebral.

Common Carotid Arteriography

• Among the most frequent cerebral angiography studies.
• Common or cervical arteries are occasionally injected before catheterizing cerebral branches.
• Common carotid artery (CCA) and bifurcation into internal and external arteries are demonstrated in PA and lateral projections.
• Carefully examine the area of bifurcation for occlusive disease.
• The right and left CCA is imaged individually

Arteriograms for Cerebral Anterior Circulation

• Lateral Projection: Center head, extend head, adjust head and adapt immobilization type
• AP Axial Projection
• AP Axial Oblique Projection: rotate the head approximately 30 degrees

Arteriography of the Posterior Blood Supply to the Brain

• AP Axial Projection adjusts the head so that the midsagittal plane is centered over and perpendicular to the IOML.
• Adjust CR to approx 1.5" superior to the glabella.
• Lateral Projection: Center head, extend to place the IOML perpendicular, and direct CR horizontally to the mastoid process 3/8" superior and 1/4" posterior to EAM.

Cerebral Venography

• AVM
• Thrombus
• Trauma
• pre/post surgical

Superior Vena Cava

• Determines if there is a thrombus or any occlusions
• CM Injection is either through a needle or catheter either located in the antecubital fossa
• Images include the opacified Subclavian Vein
• Use an intra-cath 18g positioning the patient supine and a low dose fluoro for EXPOSURE.

Pathologies

CerebroVascular Accident (CVA)

• Risk Factors: Inherited blood disorders, pregnancy
• Symptoms: Severe headache and confusion.
• IV thrombolysis - tissue Plasminogen Activator (tPA) Protein breaking down any blood clots.

Saccular Cerebral Aneurysm

• Risk factors include advanced age, hypertension and smoking
• Ruptured Saccular: Include headache, vomiting, light sensitivity, coma and death.

Arteriovenous Malformation

• AVM embolization- AVM embolized with coils, plugs, glue, onyx and absolute alcohol.

Cerebral SinoVenous Thrombosis

• Risk Factors include inherited blood disorders, difficult births
• Symptoms are severe headaches, blurred vision and confusion

Dural AV Fistulogram

• Related to Cerebral Sinovenous Thrombosis and venous hypertension
• Treated w/ embolization feeding arteries and venous angioplasty and stint placement.

Meningloma

• Most common brain tumor
• Primary central nervous system

Presentation on cerebrovascular angiography and intervention procedures. Covers intracranial vascular anatomy, diagnostic and interventional procedures for the brain and neck. Also covers vessel access techniques and equipment.