Cerebrovascular Angiography & Intervention Procedures PDF

1 Cerebrovascular Angiography & Intervention Procedures  Objectives 2 1. Describe the major vessels of the intracranial vascular anatomy 2. List and describe the various diagnostic and interventional procedures performed in the vascula...

1 Cerebrovascular Angiography & Intervention Procedures  Objectives 2 1. Describe the major vessels of the intracranial vascular anatomy 2. List and describe the various diagnostic and interventional procedures performed in the vascular anatomy of the brain and neck 3. List the indications and contraindications for angiography in these areas 4. Describe vessel access for these procedures 5. List the patient positions, projections and views used during diagnostic cerebral angiography 6. Identify the contrast agents, total amounts and injection rates used for these procedures 7. List the equipment and materials (catheters, guidewires) required for cerebral angiography 8. Identify common complications of these procedures 9. Identify the cerebral vascular anatomy and pathologies on cerebral angiograms  Aortic Arch, Neck and Brain Vascular Anatomy Review 3 Arteries: Veins:  Aortic Arch  Superior Sagittal Sinus  Brachiocephalic  Inferior Sagittal Sinus  Common Carotid (R & L)  Straight  Subclavian (R & L)  Transverse (R & L)  Internal & External Carotids (R & L)  Sigmoid Sinus  Carotid siphon  Occipital  Anterior Cerebral  Confluence of Sinuses  Middle Cerebral  Internal jugular vein (R & L)  Vertebral (R & L)  External jugular vein (R & L)  Basilar  Vertebral (R & L)  Posterior Cerebral (R & L)  Subclavian (R & L)  Anterior Communicating  Brachiocephalic (R & L)  Posterior Communicating  SVC Arteries: Aortic Arch: major artery where arteries that supply the heart, neck and head come originate Brachiocephalic: bifurcates into RT Subclavian a. and RT Common carotid a. Common Carotid (R & L): Supplies blood to brain; bifurcates at C4 level Subclavian (R & L): Rt & Lt vertebral arteries branch off respective subclavian arteries Internal carotids (R & L): supplies blood to the cerebral hemispheres, pituitary gland, orbital structures, external nose and anterior part of brain; enter the skull via the carotid canal in the petrous portion of the temporal bone; curve forward and medially; Each internal carotid artery bifurcate into anterior & middle cerebral arteries External Carotids (R & L): supplies blood to the anterior neck, face, scalp meninges, facial, maxillary, temporal and occipital regions (Facial artery, Maxillary Superficial temporal, and Occipital arteries) Carotid siphon: Part of Internal Carotid Artery just before bifurcation into Anterior Cerebral & Middle Cerebral; important area for Pathology Anterior Cerebral: Forebrain in midline; curves around corpus collosum; several branches come off this a. Middle Cerebral: Supplies lateral aspects of anterior circulation; courses toward the periphery & extends upward along lateral portion of the brain where they supply deep brain tissue Vertebral (R & L): Arise from the subclavian arteries through the transverse processes of C6-C1 and enter the brain through the foramen magnum; Supply blood to posterior brain; both converge to form the Basilar a. Basilar: Rests on the Clivus portion of sphenoid bone; Bifurcates into RT and LT Posterior Cerebral Arteries Posterior Cerebral (R & L): supplies posterior part of brain and cerebellum Anterior Communicating: Connects the two anterior cerebral arteries midline Posterior Communicating: Branches off the internal carotid artery before bifurcation; connects to the posterior cerebral a. 4 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: inferior margin of the falx cerebri; Straight sinus: The channel formed where the falx cerebri meets the tentorium cerebelli; This sinus is a continuation of the inferior sagittal sinus as it joins with the great cerebral vein Transverse (R & L): or lateral sinuses are 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 and become known as the sigmoid sinuses; they pass through the jugular foramen Galen: continues under the corpus callosum to form the internal cerebral vein Occipital sinus: smallest of dural venous sinuses; runs along inner surface of occipital bone; attached to posterior margin of falx cerebelli Confluence of Sinuses: or the Torcular Herophili; the intersection of the superior sagittal sinus, the straight sinus, the occipital sinus, & the two transverse sinuses. Its size varies and it is 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; drain the 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 occipital vein, veins of suboccipial and prevertebral muscles; drains the venous plexus that surrounds each vertebral artery; 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. They connect with the jugular form the brachiocephalic veins; Brachiocephalic (R & L): join 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 include the external jugular vein SVC: large diameter vein located in the anterior right superior mediastinum; 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;  or Innominate Artery 6  2 6 4 3 5 1  Rt vertebral a. Lt vertebral a. Rt common carotid a. Rt subclavian a. Lt subclavian a. Brachiocephalic a. or innominate a. Lt common carotid a. Aortic Arch Ascending aorta Aortic Arch common carotid a.  Arteries supplying the Anterior Brain Rt carotid siphon 10  Arteries supplying the posterior Brain 11 Rt. Vertebral artery 12 13  Review of the Cerebral Venous System 14  Cerebral Venous System 15  Cerebral Venous System 16  Cerebral Angiogram Examination  The performance of cerebral angiograms has declined, and it is no longer considered a primary diagnostic tool for cerebral pathology. However, cerebral angiography and interventional procedures remain important in interventional neuroradiology, presurgical mapping, and pre cancer radiation treatment  Much of the diagnostic investigation of pathology of the brain is using CT & MRI, especially in identifying intracranial saccular aneurysms and carotid artery disease in the neck.  Cerebral circulation time is 3 to 5 seconds long starting from the internal carotid artery to the jugular vein  Cerebral Angiogram Examination 18 Indications Contraindications Interventional & pre-surgical mapping CM sensitivity differential diagnosis advanced arteriosclerosis Aneurysms/Pseudoaneurysms extremely ill or comatose patients Arteriovenous malformations (AVM) severe hypertension Atherosclerotic Disease severe subarachnoid or stenotic lesions (neck) Trauma: blunt & penetrating of the intracerebral hemorrhaging neck/face affecting vessels CVA Evaluation of Intracranial lesions, neoplasms, gliomas, post surgery Treatment of Angiofibromas, tumors, meningiomas Arteritis  Cerebral Angiogram Examination 19 Complications  contrast agent reactions  mechanical injuries: (during vessel access or catheter placement)  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 Angiogram Examination 20  Cerebral Arteriograms done 1.Non-selective arteriogram ◼ 4 Vessel Flush of entire cerebral circulation and Aortic arch 2.Selective arteriograms to visualize the cerebral ANTERIOR circulation ◼ Common Carotid Angiogram ◼ Internal Carotid Angiogram ◼ External Carotid Angiogram 3.Selective arteriograms to visualize the cerebral POSTERIOR circulation ◼ Vertebral Arteriogram  Injection rates, Guidewire & Catheter 21 INJECTION CM & TOTAL VASCULAR/ GUIDEWIRE CATHETER TYPE TARGET VESSEL FLOW RATE VOLUME INTRODUCER DIAMETER & & FR. SIZE ML/S (ML) SHEATH LENGTH Omnipaque Non-Selective Catheter - AORTIC ARCH 22 300 Pigtail with side holes 5FR 45 - AI 4 or 5 French INTRODUCER Omnipaque SHEATH 7 COMMON CAROTID A. 300 10 to 3 cm long - 11 - HI a Longer sheath Omnipaque3 Berenstein up to 25 cm is INTERNAL CAROTID A. 6 00 4 or 5 French useful when 8 - HI J-WIRE, 0.035MM, access artery Omnipaque 180 CM LENGTH such as the EXTERNAL CAROTID A. 3 300 iliofemoral artery 5 - HI has tortuosity or Vertebral atherosclerosis Omnipaque Selective Catheter which can impair VERTEBRAL A. 5 300 4 or 5 French catheter 8 - HI navigation  CEREBRAL CIRCULATION TIME 22  Blood takes 3-5 seconds to travel from ICA to Jugular V. without CM  4.13 seconds from siphon region to the parietal veins with maximum concentration of CM  Pathologic conditions that alter the cerebral circulation time:  AVMs shortens the time  Arterial vasospasm lengthens the time  Aortic arch and 4 Vessel Flush Angiograms 23  AORTIC ARCH OPEN  350 RPO or LAO projection - Merrill’s  AORTIC ARCH SUPERIMPOSED ON ITSELF (Lateral projection)  RAO 350 to 450 useful to better show the bifurcation of the brachiocephalic and the origin of the left vertebral artery (done plane)  The inferior margin of the mandible is superimposed onto the occiput so that as much of the neck as possible is exposed in the frontal image  Image acquisition sequence is 2 to 4 images/sec. for arterial phase, and 1 image/sec for capillary (parenchymal) & venous phases  Total image acquisition time is 7 to 10 secs.  Equipment: biplane, automatic injector, DSA  CM injection rate - 22 mL/sec. total 45 mL  Catheter: 5 French pigtail; 100 cm length  Vessels demonstrated: Aortic Arch, Brachiocephalic, Rt. & Lt Subclavians and left vertebral 24 25 Simultaneous biplane oblique projections may be produced 27 PA LAO RAO 28 Arteriography of the Anterior Blood Supply to the brain  Common Carotid Arteriography  Carotid arteriograms are among the most frequently performed cerebral angiography studies  Occasionally, the common carotid arteries or cervical 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 bifurcation is studied carefully for occlusive disease  The right and left CCA are imaged individually  Rt. Common Carotid a. CCA - PA CCA - Lateral CCA - PA CCA - Lateral 31  Arteriograms for Cerebral Anterior Circulation 33  LATERAL PROJECTION - MERRILL’S  Center head to the vertically placed IR  Extend head enough to place IOML perpendicular to the horizontal  Adjust head to place midsagittal plane vertical and parallel with IR  Adapt immobilization to the type of equipment being employed.  Perform lateral projections of the anterior circulation with the CR to a point slightly cranial to the auricle and midway between the forehead and the occiput floor of the anterior fossa  AP AXIAL PROJECTION (SUPRAORBITAL) - MERRILL’S  Extend head enough to place IOML perpendicular to the CR  CR200 caudally if AP axial (200 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  AP AXIAL OBLIQUE PROJECTION (TRANSORBITAL) MERRILL’S  rotate the head approx. 300 away from injected side, or angle CR 300 toward injected side  Angle CR 200 cephalad if AP and center it to the mid-orbit of the uppermost side 34  IOML ⊥ TO IR Petrous region  Internal Carotid PA AXIAL PROJECTION (SUPRAORBITAL) Middle 20 degrees cephalad angulation Cerebral a. Anterior Cerebral a. Carotid Siphon Internal Carotid A. Extend head enough to place IOML ⊥ to the CR CR 200 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 Petrous region  Internal Carotid PA AXIAL PROJECTION (SUPRAORBITAL) Middle Cerebral a. Anterior Cerebral a. Carotid Siphon Internal Carotid A. 37 Internal Carotid LATERAL PROJECTION 38  Internal Carotid PA AXIAL OBLIQUE PROJECTION (INFRAORBITAL) 20 degrees CAUDAD angulation rotate the head approx. 300 away from injected side, or angle CR 300 toward injected side Angle CR 200 CAUDAD if PA and center it to the mid- Petrous region orbit of the uppermost side 3D Rotational Angiography Acquisitions in Lateral projection LIC - 3D RIC - 3D 40  3D Rotational Angiography RECONSTRUCTION Rt. Internal Carotid RIC - axial slices RIC - coronal slices RIC - sagittal slices 3D Rotational Angiography volumetric reconstruction Rt. Internal Carotid RIC RIC TRANSPARENT 3D Rotational Angiography volumetric reconstruction Lt. Internal Carotid LIC LIC TRANSPARENT Arteriography of the Posterior Blood Supply to the brain  Arteriograms for Posterior Circulation 45 AP Axial Projection - (Rt Vertebral) Merrill’s  Adjust head so that the midsagittal plane is centered over and perpendicular to the midline of the grid and extend the head enough so that the IOML is vertical.  CR to the region approx. 1.5” superior to the glabella at an angle of 30 to 350 caudad Rt. Vertebral a.  CR exits at the level of the EAM.  For this projection, the supraorbital margins are positioned approximately ¾” below the superior margins of the petrous ridges  Arteriograms for Posterior Circulation 46 Lateral Projection - (Rt Vertebral) Merrill’  Center the patient's head to the vertically placed IR  Extend head enough to place the IOML perpendicular to the horizontal plane, & adjust head to place the midsagittal plane vertically & parallel with IR plane  CR directed horizontally to the mastoid process at a point about 3/8” superior & ¾” posterior to EAM  Collimate to include middle & posterior brain area  Inclusion of the entire skull is not necessary  3D Rotational Angiography RECONSTRUCTION Rt. Vertebral RV - axial slices RV - coronal slices RV - sagittal slices 3D Rotational Angiography Lateral Rt. Vertebral a. RT VERTEBRAL - 3D 3D Rotational Angiography volumetric reconstruction Vertebral Arteries VERTEBRAL VERTEBRAL TRANSPARENT  Snopek - page 303 Procedure Projection Position Central Ray Anatomy Anteroposterior Median plane perpend. to IR 15 degrees caudal to enter 2.5 cm above Frontal view of the anterior and middle ML perpend. to IR glabella cerebral arteries Lateral OML perpend. to table, median Horizontally directed at right angles to film to Lateral view of anterior and middle plane parallel to IR enter 2.5 cm anterior to and 2.5 cm above cerebral arteries and their branches, external auditory meatus carotid siphon Supine oblique Median plane 30–60 degrees 15 degrees caudal to enter 2.5 cm above Anterior and middle cerebral arteries away from injected side supraorbital margin and anterior communicating artery can Carotid be delineated with lower angles angiography Transorbital OML perpendicular to IR, median 5 degrees cephalad to pass through center of Anterior and middle cerebral arteries, plane 10 degrees toward orbit carotid siphon injected side Tangential OML perpendicular to IR, median Perpendicular to IR to pass tangentially to Subdural hematoma plane 20 degrees away from or region of interest 10 degrees toward injected side Anteroposterior OML perpendicular to IR, median 25 degrees caudal in median plane, entering Vertebrobasilar system plane perpend. to IR at frontal bone and passing through external auditory meatus Vertebral angiography Lateral OML perpendicular to table, Horizontally directed at right angles to IR to median plane parallel to IR enter 2.5 cm posterior to external auditory meatus  Cerebral Venography Indications:  AVM  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 to r/o thrombus or occlusion  CM Injection either thru 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  Mid chest area 1” to right side form mid sagittal plane PT. INJECTION CATHETER EXPOSURE FPS POSITION RATE intracath Low dose HAND DSA SUPINE 18g fluoro INJ 2fps Superior Vena Cava 53 Venous Sinuses 55  Pathologies: Cerebro Vascular Accident (CVA or Stroke)  Risk Factors: inherited blood disorders, certain cancers, meds, infections, pregnancy, birth control, TEACHING OR STUDYING AT DAWSON  Symptoms: severe headache (most common), blurred vision, confusion, loss of consciousness and movement control, seizures, coma, vein ruptured causing venous hemorrhagic stroke  Symptoms of Occlusion of the Anterior cerebral a. include contralateral loss of sensation and motor control to lower body  Symptoms of Occlusion of the middle cerebral a. include contralateral loss of sensation & motor control to face & upper limbs  Symptoms of Occlusion of the posterior cerebral a. include contralateral loss of vision  diagnosed with CT - MRI  Cerebro Vascular Accident (CVA or Stroke) 57 Medication Treatments 1. blood thinners - long term treatment 2. IV thrombolysis - tissue Plasminogen Activator (tPA) protein that breaks down blood clots Interventional Treatments 1. Intravascular Thrombolysis (Fibrinolysis) o streptokinase & urokinase substances o infusing catheter is placed in the obstructed area Endovascular Thrombectomy 2. Endovascular Thrombectomy (Done at the MNH) 3. Balloon Embolectomy - risk of causing PE 4. Angiojet rheolytic mechanical thrombectomy - thrombi is suctioned into catheter where it is fragmented by small jets coming out of side ports of the catheter Rt Vertebral a. occlusion - PTA & Stent Middle Cerebral a. occlusion - Placement Procedure Mechanical Thrombectomy Procedure  Rt. Middle Cerebral a. Occlusion LCC - middle cerebral a. LIC - middle cerebral a. LIC - middle cerebral a. occlusion - LATERAL occlusion - PA occlusion - LATERAL 59 Rt. Middle Cerebral a. Occlusion LIC - middle cerebral a. occlusion - POST LIC - middle cerebral a. occlusion - POST THROMBECTOMY - PA THROMBECTOMY - LATERAL  Pathologies: Cerebral Aneurysm 62  Aneurysm:  A true aneurysm affects all 3 layers of the arterial wall (intima, media, & adventitia)  A false aneurysm, also known as Pseudoaneurysm, involves only the outer layer of the artery (adventitia)  Depending on their shape, they can be saccular or fusiform. ◼ saccular cerebral aneurysms (also known as berry aneurysms) have a 90% occurrence ◼ Aortic aneurysms are about 94% fusiform ◼ Aneurysms can be classified based on their location  Cerebral saccular aneurysms are treated with coil embolization  Fusiform Aneurysms most often treated with stents  Saccular Cerebral Aneurysms 63 Risk factors of Saccular Signs and symptoms of unruptured Signs and symptoms of ruptured Cerebral Aneurysms cerebral aneurysm include cerebral aneurysm include  Advanced age  Headache  Headache  Hypertension  Eye pain  Nausea and vomiting  Excessive alcohol  Unilateral complete third cranial  Nuchal rigidity consumption nerve palsy  Altered mental status  Cigarette smoking  Ischemic/embolic  Eye pain  Atherosclerosis of cerebrovascular disease  Unilateral complete third the cerebral arteries  Seizures cranial nerve palsy  Trauma to the head  Vision loss or hemianopsia  Loss of consciousness  Use of illicit drugs  Photophobia such as cocaine  Focal neurologic deficits  Estrogen deficiency  Coma and death vertebrobasilar junction aneurysm Anterior Communicating A. Saccular Aneurysm ARTERIOGRAMS 67 Anterior Communicating A. Saccular Aneurysm CT RECONSTRUCTED IMAGE SERIES 68 ANT. COMM. ANEURYSM - OBLIQUE PROJECTION - GW & MICROCATHETER PLACEMENT USING ROADMAPPING 69 ANT. COMM. ANEURYSM - POST COIL EMBOLIZATION - PA & LATERAL PRE-EMBOLIZATION POST-EMBOLIZATION  Pathologies: ARTERIOVENOUS MALFORMATION (AVM)  Abnormal anastomosis or communication between an artery and a vein.  AVM Embolization - Interventional procedure - AVM is embolized with coils, plugs, glue, onyx, absolute alcohol, CEREBRAL AVM EMBOLIZATION 73  Pathologies: Cerebral SinoVenous Thrombosis (CSVT)  Slow thrombi formation in a cerebral vein - CVA - Stroke ◼ It happens over time due to development of collaterals to bypass the obstruction  Fact: This rare blood clot disorder prompted stop the use of Johnson & Johnson COVID-19 vaccine, as well as the AstraZeneca vaccine.  Risk Factors: inherited blood disorders, certain cancers, meds, infections, pregnancy, birth control, difficult birth babies  Symptoms: severe headache most common), blurred vision, confusion, loss of consciousness and movement control, seizures, coma, vein ruptured causing venous hemorrhagic stroke  Often misdiagnosed with CT - MR Venography most effective  Pathologies: Cerebral SinoVenous Thrombosis (CSVT) 75 Treatment:  blood thinners - long term treatment  IV thrombolysis (tPA = tissue plasminogen activator = protein = breaks down blood clots)  Intravascular Thrombolysis (Fibrinolysis)  infusing catheter is placed in the obstructed area  streptokinase & urokinase substances  Thrombectomy  Balloon Embolectomy - risk of causing PE  Angiojet rheolytic mechanical thrombectomy = thrombi suctioned into catheter where it is fragmented by small jets coming out of side ports of the catheter 76  Pathologies: Dural AV Fistulogram  Due to cerebral sinovenous thrombosis (CSVT) or venous hypertension  Symptoms: severe headache, tinnitus, confusion  MRI & CT modalities for diagnosis  Treated with embolization of feeding arteries and venous angioplasty and stent placement  EndovascularTreatmentofDuralA rteriovenousFistula.pdf Angiogram of the right vertebral artery shows a dural arteriovenous fistula filling the transverse sinus and causing cortical vein reflux (arrow) (a); embolization was performed with Onyx through the artery (b).  Post embolization of fistula arterial feeder and angioplasty and stent deployment in transverse vein 78  Pathologies: Meningioma  Meningioma  Most common brain tumor  primary central nervous system (CNS) tumor  arises from the meninges  it begins in the brain or spinal cord  RIGHT INTERNAL CAROTID - HEMINGIOMA RIGHT EXTERNAL CAROTID HEMINGIOMA RIC- MENINGIOMA - LATERAL RIC- MENINGIOMA - OBLIQUE - LAO RIC- MENINGIOMA - PA RIC- MENINGIOMA - OBLIQUE - RAO 80  Pathologies SVC Stenosis 81