Interventional 2 test 1 (topic 2)

Cerebrovascular Angiography & Intervention Procedures

• This presentation covers cerebrovascular angiography and intervention procedures.

Objectives

• To describe the major vessels of the intracranial vascular anatomy.
• To list and describe various diagnostic and interventional procedures performed in the vascular anatomy of the brain and neck.
• To list the indications and contraindications for angiography in these areas.
• To describe vessel access for these procedures.
• To list the patient positions, projections, and views used during diagnostic cerebral angiography.
• To identify the contrast agents, total amounts, and injection rates used for these procedures.
• To list the equipment and materials, such as catheters and guidewires, required for cerebral angiography.
• To identify common complications of these procedures.
• To identify the cerebral vascular anatomy and pathologies on cerebral angiograms.

Aortic Arch, Neck and Brain Vascular Anatomy Review

Arteries:

• Aortic Arch: Major artery where arteries supplying the heart, neck, and head originate.
• Brachiocephalic: 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): The right and left vertebral arteries branch off their respective subclavian arteries.
• Internal Carotids (R & L): Supplies blood to the cerebral hemispheres, pituitary gland, orbital structures, external nose, and the anterior part of the brain; enters the skull via the carotid canal in the petrous portion of the temporal bone and each internal carotid artery bifurcates into the anterior and middle cerebral arteries.
• External Carotids (R & L): Supplies blood to the anterior neck, face, scalp meninges, and facial, maxillary, temporal, and occipital regions via the facial, maxillary, superficial temporal, and occipital arteries.
• Carotid Siphon: The part of the internal carotid artery just before it bifurcates into the anterior and middle cerebral arteries; is an important area for pathology.
• Anterior Cerebral: Located in the forebrain, midline, curves around the corpus callosum, and has several branches.
• Middle Cerebral: Supplies lateral aspects of the anterior circulation, courses toward the periphery, and extends upward along the lateral portion of the brain where it supplies deep brain tissue.
• Vertebral (R & L): Arises from the subclavian arteries through the transverse processes of C6-C1, enters the brain through the foramen magnum, supplies blood to the posterior brain, and both converge to form the basilar artery.
• Basilar: rests on the Clivus portion of the sphenoid bone and bifurcates into the right and left posterior cerebral arteries.
• Posterior Cerebral (R & L): Supplies the posterior part of the brain and cerebellum.
• Anterior Communicating: Connects the two anterior cerebral arteries midline.
• Posterior Communicating: Branches off the internal carotid artery before bifurcation and connects to the posterior cerebral artery.

Veins:

• Dural Venous Sinuses: Venous drainages found between the inner and outer layers of the dura mater.
• Superior Sagittal Sinus: Found in the superior border of the falx cerebri.
• Inferior Sagittal Sinus: Located on the inferior margin of the falx cerebri.
• Straight Sinus: The channel formed where the falx cerebri meets the tentorium cerebelli; a continuation of the inferior sagittal sinus which joins with the great cerebral vein.
• Transverse (R & L): Lateral sinuses found along the lateral aspect of the tentorium cerebelli as it meets the occipital bone.
• Sigmoid Sinus: At the level of the petrous portions of the temporal bones, the transverse sinuses curl medially and inferiorly; they pass through the jugular foramen.
• Galen: Continues under the corpus callosum to form the internal cerebral vein.
• Occipital Sinus: The smallest of the dural venous sinuses, runs along the inner surface of the occipital bone, attached to the posterior margin of falx cerebelli.
• Confluence of Sinuses: Known as Torcular Herophili; the intersection of the superior sagittal sinus, the straight sinus, the occipital sinus, and the two transverse sinuses; located inferior to the occipital lobes and postero-superiomedially to the cerebellum.
• Internal Jugular Vein (R & L): Extends from the base of the skull to the sternal end of the clavicle; drains venous blood from the majority of the skull, brain, and superficial structures of the head and neck; drains from sigmoid sinus.
• External Jugular Vein (R & L): Drains most of the outer structures of the head, including the scalp and deep portions of the face; drains into the subclavian vein.
• Vertebral (R & L): Union of internal vertebral venous plexuses, a branch of the occipital vein, veins of suboccipital and prevertebral muscles; drains the venous plexus surrounding each vertebral artery and drains to the brachiocephalic veins; the vertebral vein leaves the sixth cervical transverse foramen and empties into the brachiocephalic vein.
• Subclavian (R & L): Continuation of the axillary vein, located underneath the clavicle; connects with the jugular form the brachiocephalic veins
• Brachiocephalic (R & L): Joins to the superior vena cava, where the blood is drained directly into the left atrium of the heart; a main tributary vein of the subclavian vein includes the external jugular vein
• SVC: A large diameter vein located in the anterior right superior mediastinum that drains the brachiocephalic veins and azygos vein; begins behind the lower border of the 1st right costal cartilage and descends vertically behind the 2nd and 3rd intercostal spaces to drain into the right atrium at the level of the 3rd costal cartilage.

Cerebral Angiogram Examination

• The use of cerebral angiograms has declined as it is no longer considered a primary diagnostic tool, but it is still important for interventional neuroradiology, presurgical mapping and pre-cancer radiation treatment
• CT and MRI are used to investigate pathology of the brain, specifically intracranial saccular aneurysms and carotid artery disease of the neck
• Cerebral circulation has a time of 3-5 seconds from the internal carotid artery to the jugular vein.

Cerebral Angiogram Examinations - Indications

• Interventional & Pre-surgical mapping.
• Differential diagnosis.
• Aneurysms/Pseudoaneurysms.
• Arteriovenous malformations (AVM).
• Atherosclerotic disease.
• Stenotic lesions, specifically in the neck.
• Blunt and penetrating trauma, primarily to the neck and face affecting vessels.
• CVA (Cerebrovascular Accident).
• Evaluation of intracranial lesions, neoplasms, and gliomas, and after surgery.
• Treatment of Angiofibromas, tumors and meningiomas.
• Arteritis.

Cerebral Angiogram Examinations - Contraindications

• CM sensitivity.
• Advanced arteriosclerosis.
• Those who are extremely ill or comatose.
• Severe hypertension.
• Severe subarachnoid or intracerebral hemorrhaging.

Cerebral Angiogram Examinations - Complications

• contrast agent reactions
• Mechanical injuries during vessel access or catheter placements include hemorrhage, arteriovenous fistula, mechanical obstruction, pseudoaneurysm, vessel lacerations, hematoma at the puncture site, and extravasation of CM
• physiologic complications
  • Stroke due to dislodged embolus or the introduction of foreign materials during the procedure.
  • Transient ischemic attacks (TIAs)

Cerebral Arteriograms

• Cerebral Arteriograms can be done performing - Non-selective arteriogram or Selective arteriograms
• Non-selective arteriogram
  • 4 Vessel Flush of the entire cerebral circulation along with the Aortic arch
• Selective arteriograms to visualize the cerebral ANTERIOR circulation
  • Common Carotid Angiogram
  • Internal Carotid Angiogram
  • External Carotid Angiogram
• Selective arteriograms to visualize the cerebral POSTERIOR circulation
  • Vertebral Arteriogram

Injection rates, Guidewire & Catheter

• Aortic Arch: Injection Flow Rate of 22 ml/s, Contrast Medium and Total volume used is Omnipaque 300, 45 ml and a Non-selective Catheter- Pigtail with side holes 4 or 5 French, 5FR Introducer sheath.
• Common Carotid Artery: Injection Flow Rate of 7 ml/s, Contrast Medium and Total volume used is Omnipaque 300, 11 ml and a Berenstein 4 or 5 French, J-wire with diameter of 0.035 and a 180cm Length is used.
• Internal Carotid Artery: Injection Flow Rate of 6 ml/s, Contrast Medium and Total volume used is Omnipaque 300, 8 ml and a Vertebral Selective Catheter 4 or 5 French, J-wire with diameter of 0.035 and a 180cm Length is used.
• External Carotid Artery: Injection Flow Rate of 3 ml/s, Contrast Medium and Total volume used is Omnipaque 300, 5 ml and a Vertebral Selective Catheter 4 or 5 French, J-wire with diameter of 0.035 and a 180cm Length is used.
• Vertebral Artery: Injection Flow Rate of 5 ml/s, Contrast Medium and Total volume used is Omnipaque 300, 8 ml and a Vertebral Selective Catheter 4 or 5 French, J-wire with diameter of 0.035 and a 180cm Length is used.

Cerebral Circulation Time:

• It takes ≈ 3-5 seconds to travel from the ICA to the Jugular V without CM
• It takes ≈ 4.13 seconds from the siphon region to the parietal veins with maximum concentration of CM
• Arteriovenous malformations (AVMs) shortens the time
• Arterial vasospasm lengthens the time

Aortic Arch and 4 Vessel Flush Angiograms:

• Aortic Arch Open: Use a 35° RPO or LAO projection (Merrill's).
• Aortic Arch Superimposed on Itself: Use a RAO 35-45° to better visualize the bifurcation of the brachiocephalic and origin of the left vertebral artery.
• The inferior margin of the mandible is superimposed onto the occiput to allow for as much of the neck to be exposed in the frontal image.
• Image acquisition: 2-4 images/sec for the arterial phase, and 1 image/sec for capillary (parenchymal) and venous phases. Total image aquisition time of 7-10secs
• Equipment: Biplane, automatic injector, and DSA (Digital Subtraction Angiography).
• CM injection: 22 mL/sec, total 45 mL.
• Catheter: 5 French pigtail and 100 cm length.
• Demonstrated vessels: Aortic Arch, Brachiocephalic, Rt. & Lt Subclavians, and left vertebral.

Common Carotid Arteriography

• Among the most frequently preformed angiogram.
• The common carotid arteries are injected before catheterization of the cerebral branches.
• The common carotid artery(CCA) and its bifurcation into internal and external carotid arteries are demonstrated in the PA and lateral projections.
• The area of the bifurcation is carefully studied for occlusive diseases.
• The right and left CCA are imaged individually.

Arteriograms for Cerebral Anterior Circulation

• Lateral Projection - Merrill's:
  • Center head to the vertically placed IR (Image Receptor).
  • Extend the head to place the IOML (Infraorbital Meatal Line) perpendicular to horizontal.
  • Adjust head to place midsagittal plane vertical and parallel with IR.
  • Adapt immobilization to the type of equipment being employed.
  • For lateral projections, use an X Ray beam directed to a point slightly cranial to the auricle and midway between the forehead and the occiput.
• AP Axial Projection (Supraorbital) - Merrill's:
  • Extend head enough to place IOML (Infraorbital Meatal Line) perpendicular to the CR (Central Ray).
  • Perform the exam with the part tilted 20 degrees away to angle CR.
• AP Axial Oblique Projection (Transorbital) Merrill's:
  • Rotate the head approximately 30 degrees away from the injected side or Angle CR (Central Ray) 30 degrees toward the injected side
  • Angle CR 20 degrees cephalad if AP(Anterior Posterior) and center it to the mid-orbit of the uppermost side.

Arteriography of the Anterior Blood Supply to the Bain - Projections

• Perform Internal Carotid PA AXIAL PROJECTION with the angle tilted 20 degrees cephalad.

  • Extend the head enough the IOML (Infraorbital Meatal Line) is perpendicular to the CR.
  • CR 20 º cephalad if PA axial along a line passing ¾" superior to and parallel with a line extending from the supraorbital margin to a point ¾” superior to the EAM (External Auditory Meatus).

• Perform Internal Carotid LATERAL PROJECTION

• Perform Internal Carotid PA AXIAL OBLILQUE PROJECTION (INFRAORBITAL)

  • Rotate the head approximately 30° away from injected side
  • Angle CR at 30° toward injected side
  • Angle CR 20° CAUDAD if PA and center it to the mid-orbit of the uppermost side

Arteriograms for Posterior Circulation - AP Axial Projection (Rt Vertebral) Merrill's

• Adjust the head so that the midsagittal plane is centered over and perpendicular to the midline of the grid
• Extend the head enough so that the Infraorbital Meatal Line (IOML) is vertical.
• CR (Central Ray) to the region approx. 1.5" superior to the glabella at an angle of 30 to 35° caudal. CR exits at the level of the EAM (External Auiditory Meatus)
• The supraorbital margines are Positioned approximately 3½ Below the superrior margines of the petrous ridge

Arteriograms for Posterior Circulation - Lateral Projections (Rt Vertebral) Merrill's

• Center the patient's head vertically.
• Extend head to place the IOML perpendicular to the horizontal plane, and adjust head to place the midsagittal plane vertically/parallel with the Image Receptor
• CR beam should be projected horizontally, with the beam hitting towards the mastoid

Cerebral Venography - Indications

• AVM (Arteriovenous Malformation).
• Thrombus.
• Evaluation of tumors.
• Trauma.
• Pre/post surgical.
• Inferior petrosal venous sampling for ACTH levels.
• Measurement of the AdrenoCorticoTropic Hormone.

Cerebral Venography - Superior Vena Cava

• Primarily performed to rule out thrombus or occlusion
• Inject CM (Contrast Media) either through a needle or angiographic catheter in a vein located in the antecubital fossa
• Images should include the opacified subclavian vein, brachiocephalic vein, superior vena cava, and Rt atrium
• The injected vessel, the chest area to form mid-sagittal plane
• Utilized intracath of 18g and the patient is placed SUPINE with Lowa dase fluora, the Contrast Media is injected HAND INJ and fps (frames per second) are recorded as DSAs during imaging

Pathologies:

Cerebro Vascular Accident (CVA or Stroke)

• Risk Factors: inherited blood disorders, certain cancers, medications, infections or pregnancy.
• Symptoms: severe headache, blurred vision, confusion, loss of consciousness and movement control, seizures, coma, vein rupture causing venous hemmoraghic stroke

CVA or Stroke - Medication Treatments

• blood thinners - long term treatment
• IV thrombolysis - tissue plasminogen activator (tPA) protein that breaks down blood clots

CVA or Stroke - Interventional Treatments

• Intravascular Thrombolysis (Fibrinolysis). Uses streptokinase and urokinase and infusion happens at the obstructed area via catheter.
• Endovascular Thrombectomy performed at (MNH).
• Balloon Embolectomy, there is a risk of causing PE(Pulmonory Embolism) during this procedure
• Angiojet rheolytic mechanical thrombectomy removes thrombi by suctioning them where is fragemented into small jets.

Pathologie - Aneurysm

• Involves all 3 layers of the arterial wall (intima, media, adventitia)
• The area can contain a saccular or fusiform

Conditions with Cerebal Aneruysm

• Saccular Cerebral Aneurysms has 90% of occurance
• Aortic Anuerysms are often 94%
• Cerebal Saccar Anuerysms are Treated with coil embolization
• Fusiform anuerysms are often treated with stends
• Ruptured Cerebal Anuerysms has a Risk factor that includes : Inherited blood disorders, trauma and ilicitc Drugs

Ruptured Saccular Cerebral Aneurysms - Signs and Symptoms

• Headaches
• Nausea and Vomitting
• Nucleal Rigdity
• Altered Mental Status
• Coma and Death

Pathologies: Arteriovenous Malformation (AVM)

• Abnormal anastomosis/communication between an artery and vein.
• AVM Embolization is the Embolizing the AVM using - Coils, Plugs, Glues, and Onyx.

Cerebral SinoVenous Thrombosis (CSVT)

• slow thrombi formation in a cerebral vein indicates CVA - Stroke as it happens over time.
• the slow Thromboli is often prompted by stop the use of Johnson COVID-19 vaccine, as well as the AstraZeneca vaccine.
• Signs and Symptoms Include Severe headacher with Blurred vision. Common symptoms of this is also the loss of Conciousness and movement
• Treatment: - blood thinner to break down protein clts in the vein and balloon embelcormoy
• Balloon Embolectomy - risk of causing PE.

Pathologies: Meningioma

• This is the most common brain tumor, which is a primary central nervous system (CNS) tumor.
• Starts with a formation in the brain
• Is a tumor the is not a meninges or menigniomma.

Cerebral Venous Sinus Thrombosis (CVST)

• Use Slow throbi formation in a cerebal vein - (CVA Stroke)
• this often happens because there is a slow development collateral which bypasseses the abstructrion

Pathologies - Meningioma

• Most Common brain Tumor
• a Primary Centrla Nevous system (CNS) Tumor which often originiates to an area of the Mninges.