Textbook of Interventional Neurology PDF

This page intentionally left blank Textbook of Interventional Neurology Textbook of Interventional Neurology Edited by Adnan I. Qureshi Zeenat Qureshi Stroke Research Center Minneapolis, MN Associate Editor Alexandros L. Georgiadis Zeenat Qureshi Stroke Research Center Minneapolis, MN CAMBRIDGE UNIVERSITY PRESS Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo, Delhi, Dubai, Tokyo, Mexico City Cambridge University Press The Edinburgh Building, Cambridge CB2 8RU, UK Published in the United States of America by Cambridge University Press, New York www.cambridge.org Information on this title: www.cambridge.org/9780521876391 # Cambridge University Press 2011 This publication is in copyright. Subject to statutory exception and to the provisions of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press. First published 2011 Printed in the United Kingdom at the University Press, Cambridge A catalog record for this publication is available from the British Library Library of Congress Cataloging-in-Publication Data Textbook of interventional neurology / edited by Adnan I. Qureshi ; associate editor, Alexandros L. Georgiadis. p. cm. Includes bibliographical references and index. ISBN 978-0-521-87639-1 (Pbk.) 1. Brain–Endoscopic surgery. 2. Brain–Blood-vessels–Endoscopic surgery. 3. Brain–Tumors–Endoscopic surgery. 4. Cerebrovascular disease– Endoscopic surgery. I. Qureshi, Adnan I. II. Georgiadis, Alexandros L. III. Title. [DNLM: 1. Cerebrovascular Disorders–surgery. 2. Brain Neoplasms– surgery. 3. Catheterization–methods. 4. Endoscopy–methods. 5. Surgical Procedures, Minimally Invasive–methods. 6. Vascular Surgical Procedures–methods. WL 355 T3546 2011] RD594.2.T49 2011 617.40 810597–dc22 2010023938 ISBN 978-0-521-87639-1 Paperback Cambridge University Press has no responsibility for the persistence or accuracy of URLs for external or third-party internet websites referred to in this publication, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate. Every effort has been made in preparing this book to provide accurate and up-to-date information which is in accord with accepted standards and practice at the time of publication. Although case histories are drawn from actual cases, every effort has been made to disguise the identities of the individuals involved. Nevertheless, the authors, editors and publishers can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation. The authors, editors and publishers therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this book. Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use. Contents List of contributors vi 1 History of interventional neurology 1 13 Intracranial arteriovenous malformations 255 Adnan I. Qureshi Dorothea Strozyk, Carlos E. Baccin, Johnny C. Pryor and 2 Diagnostic cerebral angiography 10 Raul G. Nogueira Adnan I. Qureshi and Ameer E. Hassan 14 Intracranial dural arteriovenous ﬁstulas 285 3 Pathophysiological and pharmacological Thanh N. Nguyen, Jean Raymond, Alexander M. Norbash treatment of thromboembolic and ischemic and Daniel Roy complications associated with endovascular 15 Cerebral sinus thrombosis 299 procedures 30 Amit Singla and Randall C. Edgell Ameer E. Hassan, Steve M. Cordina, Haitham H. Hussein, Deepak L. Bhatt and Adnan I. Qureshi 16 Intracranial and head and neck tumors: embolization and chemotherapy 312 4 Peri-procedural care 58 Adnan I. Qureshi, Nauman Tariq, Rabia Qaiser, Alexandros L. Georgiadis, Mustapha A. Ezzeddine and Herbert B. Newton and Stephen J. Haines Adnan I. Qureshi 17 Diagnostic and provocative testing 357 5 Acute ischemic stroke 69 Haralabos Zacharatos, Ameer E. Hassan, M. Fareed Alexandros L. Georgiadis, Georgios Tsivgoulis, Andrei V. K. Suri and Adnan I. Qureshi Alexandrov, Adnan I. Qureshi and José I. Suarez 18 Spinal vascular and neoplastic lesions 388 6 Cervical internal and common carotid artery Osman S. Kozak, Edgard Pereira and Adnan I. Qureshi stenosis 95 Adnan I. Qureshi and L. Nelson Hopkins 19 Central retinal artery occlusion 404 Alberto Maud, Muhammad Zeeshan Memon, M. Fareed 7 Extracranial vertebral artery disease 130 K. Suri and Adnan I. Qureshi Robert A. Taylor, Muhammad Zeeshan Memon and Adnan I. Qureshi 20 Epistaxis 419 Alexandros L. Georgiadis, Steve M. Cordina, Haralabos 8 Intracranial stenosis 145 Zacharatos and Adnan I. Qureshi Farhan Siddiq, Muhammad Z. Memon, Adnan I. Qureshi and Camilo R. Gomez 21 Vertebroplasty and kyphoplasty 428 Stanley H. Kim, Anant I. Patel, Nancy Gruell, Kirk Conrad 9 Extracranial and intracranial arterial dissections 166 and Young J. Yu YihLin Nien, José Rafael Romero, Thanh N. Nguyen and Adnan I. Qureshi 22 Clinical endovascular trials in stroke 447 Haitham M. Hussein and Adnan I. Qureshi 10 Traumatic vascular injury 179 Jefferson T. Miley, Qaisar A. Shah and Adnan I. Qureshi 23 Qualiﬁcation requirements for performing neuro-interventional procedures 466 11 Intracranial aneurysms 197 Adnan I. Qureshi, Alex Abou-Chebl and Tudor G. Jovin Alexandros L. Georgiadis, Matthew D. Ford, David A. Steinman, Nauman Tariq and Adnan I. Qureshi 12 Cerebral vasospasm 230 Adnan I. Qureshi, Mushtaq H. Qureshi, Jefferson Index 482 T. Miley, Nauman Tariq and Giuseppe Lanzino Color plate section between pp. 246 and 247. v Contributors Alex Abou-Chebl MD Randall C. Edgell MD Director of Neurointerventional Services and Assistant Professor of Neurology and Neurosurgery Assistant Professor of Neurology and Neurosurgery Department of Neurology University of Louisville St. Louis University Louisville, KY St. Louis, MO USA USA Andrei V. Alexandrov MD Mustapha A. Ezzeddine MD Director, Division of Cerebrovascular Disease Associate Professor of Neurology and Neurosurgery Director, Comprehensive Stroke Research Center and Department of Neurology Professor of Neurology, Zeenat Qureshi Stroke Research Center University of Alabama Hospital University of Minnesota Birmingham, AL Minneapolis, MN USA USA Carlos E. Baccin MD Matthew D. Ford PhD Clinical Fellow Postdoctoral Fellow Department of Interventional Radiology Biomedical Stimulation Laboratory Hospital Beneficência Portuguesa University of Toronto Sao Paulo Toronto, ON Brazil Canada Deepak L. Bhatt MD Alexandros L. Georgiadis MD Chief of Cardiology, VA Boston Healthcare System Adjunct Assistant Professor of Neurology Associate Professor of Medicine, Department of Neurology Harvard Medical School and Zeenat Qureshi Stroke Research Center Director, Integrated Interventional Cardiovascular Program University of Minnesota Brigham and Women’s Hospital and Minneapolis, MN VA Boston Healthcare System USA Boston, MA USA Camilo R. Gomez MD, MBA Director, Alabama Neurological Institute Kirk Conrad MD Birmingham, AL Austin Radiological Association, USA Austin, TX USA Nancy Gruell RN St. David’s Medical Center Steve M. Cordina MD Austin, TX Endovascular Surgical Neuroradiology Fellow USA Department of Neurology University of Minnesota Stephen J. Haines MD Minneapolis, MN Lyle A. French Chair, Professor and Head USA Department of Neurosurgery vi List of contributors University of Minnesota Paul L. Foster School of Medicine Minneapolis, MN Texas Tech University Health Science Center USA El Paso, TX USA Ameer E. Hassan DO Endovascular Surgical Neuroradiology Fellow Muhammad Z. Memon MD Zeenat Qureshi Stroke Research Center Pre-residency Fellow University of Minnesota Department of Neurosurgery Minneapolis, MN Zeenat Qureshi Stroke Research Center USA University of Minnesota Minneapolis, MN L. Nelson Hopkins MD USA Department of Neurosurgery Kaleida Health Jefferson T. Miley MD Buffalo, NY Vascular and Interventional Neurology USA Neurosurgery, Endovascular & Spine Center Austin, TX Haitham H. Hussein MD USA Zeenat Qureshi Stroke Research Center Resident of Neurology Herbert B. Newton MD University of Minnesota Professor of Neurology, Neurosurgery and Oncology Minneapolis, MN James Cancer Hospital USA Columbus, OH USA Tudor G. Jovin MD Co-Director, UPMC Stroke Unit Thanh N. Nguyen MD Co-Director, UPMC Center for Assistant Professor Neurology Neuroendovascular Therapy Boston University Medical Center UPMC Stroke Institute Boston, MA Pittsburgh, PA USA USA YihLin Nien MD Stanley H. Kim MD Stroke Fellow Director of Neurovascular Surgery Boston University Medical Center Neurosurgery, Endovascular and Spine Center Natick, MA Austin, TX USA USA Raul G. Nogueira MD Osman Kozak MD Assistant Professor in Neurology and Radiology Associate Director Neurointerventional and Department of Interventional Neuroradiology Neurocritical Care Massachusetts General Hospital Abington Memorial Hospital Boston, MA Willow Grove, PA USA USA Alexander M. Norbash MD Giuseppe Lanzino MD Professor and Chair of Radiology Professor of Neurosurgery Boston University Medical Center Mayo clinic Boston, MA Rochester, MN USA USA Anant I. Patel MD Alberto Maud MD Neurosurgeon Endovascular Surgical Neuroradiology Endovascular and Spine Center Assistant Professor Austin, TX Department of Neurology USA vii List of contributors Edgard Pereira MD Montreal, Quebec Director, Interventional Neuroradiology Service Canada Department of Radiology JFK Medical Center Qaisar A. Shah MD Atlantis, FL Director, Neurointerventional and Neurocritical Care USA Neurovascular Association of Abington Willow Grove, PA Johnny C. Pryor MD USA Instructor in Neurosurgery Harvard Medical School Farhan Siddiq MD Director of Interventional Neuroradiology and Endovascular Neurosurgery Resident Neurosurgery Zeenat Qureshi Stroke Research Center Massachusetts General Hospital Department of Neurology Boston, MA University of Minnesota USA Minneapolis, MN Rabia Qaiser MD USA Resident, Department of Neurosurgery Amit Singla MD University of Minnesota Neurosurgery Resident St. Louis Park, MN Department of Neurosurgery USA SUNY Upstate University Hospital Adnan I. Qureshi MD Syracuse, NY Associate Head and Professor USA Zeenat Qureshi Stroke Research Center Department of Neurology David A. Steinman PhD University of Minnesota Professor of Mechanical and Minneapolis, MN Biomedical Engineering USA University of Toronto Toronto, ON Mushtaq H. Qureshi MD USA Research Fellow Zeenat Qureshi Stroke Research Center Dorothea Strozyk MD University of Minnesota Interventional Neuroradiology Fellow Minneapolis, MN New York Presbyterian Hospital USA Columbia University College of Physicians and Surgeons Jean Raymond MD New York, NY Interventional Neuroradiology Research Laboratory USA Centre hospitalier de l’Université de Montréal-Hôpital Notre-Dame Jose I. Suarez MD Montreal, Quebec Professor of Neurology Canada Baylor College of Medicine Houston, TX José Rafael Romero MD USA Assistant Professor, Neurology M. Fareed K. Suri MD Boston University Medical Center Assistant Professor of Neurology Boston, MA University of Minnesota USA Minneapolis, MN USA Daniel Roy MD Professor of Radiology Nauman Tariq MD Centre hospitalier de l’Université de Montréal-Hôpital Clinical Research Fellow Notre-Dame Zeenat Qureshi Stroke Research Center viii List of contributors University of Minnesota Alexandroupolis Minneapolis, MN Greece USA Young J. Yu MD Robert A. Taylor MD Neurosurgeon Assistant Professor Mount Saint Mary’s Hospital Zeenat Qureshi Stroke Research Center Niagara Falls Departments of Neurology, New York, NY USA Neurosurgery and Radiology Haralabos Zacharatos MD University of Minnesota Neurology Resident Minneapolis, MN Zeenat Qureshi Stroke Research Center USA Department of Neurology Georgios Tsivgoulis MD University of Minnesota Lecturer of Neurology Minneapolis, MN Democritus University of Thrace USA ix Chapter 1 History of interventional neurology Adnan I. Qureshi MD Interventional neurology is a subspecialty of neurology that uses catheter technology, radiological imaging, and clinical The journey starts: Egas Moniz expertise to diagnose and treat diseases of the central nervous and cerebral angiography system.1 Interventional Neurology was a term that was used In 1928, Egas Moniz became a Professor of Medicine and by Dr. Kori2 in his article on issues of neurological practice subsequently Chair of Neurology at University of Lisbon in section in Neurology entitled “Interventional neurology: a Portugal.3 Since 1927, Dr. Moniz had attempted percutaneous subspecialty whose time has come.” He recommended per- injection of internal carotid artery in four patients, but was formance of computed tomographic and magnetic resonance limited by irritation of tissue by contrast, intravascular con- imaging guided procedures including nerve blocks, biopsies, trast dilution, and radiological equipment. Subsequently, aspirations, and destructive procedures; intra-arterial proced- direct injection was attempted after surgical exposure of the ures including carotid angioplasty, carotid thrombolysis, internal carotid artery. In his paper in Revue Neurologique4 in embolizations, chemotherapy, and blood–brain barrier modi- 1927, Dr. Moniz states the objective of his initial work to ﬁcation; interventional neurosonology; eletromyographic identify an opaque, non-oily substance which can easily pass guided procedure including Botulinum toxin injections, trig- through the capillaries for visualization of arteries. Iodides ger point injections; and nerve ﬁnder guided procedures to (compared with bromides) performed better as contrast media be included in this subspecialty. Over the last two decades, because of higher radio-opacity when injected in carotid arter- the deﬁnition has evolved to a more focused deﬁnition, ies of cadavers in 30%, 20%, 10%, and 7.5% solutions. All which only includes procedures that are recognized as part solutions were found to opacify intracranial arteries despite of the training requirements of the “Endovascular Surgical the presence of cranium. Dr. Moniz then injected strontium Neuroradiology” fellowship according to Accreditation bromide, lithium bromide, and sodium iodide into the Council for Graduate Medical Education (ACGME). The common carotid arteries of dogs to obtain radiographs and advent of interventional neurology as a subspecialty has determine toxicity and effect of dilution from ongoing blood created an opportunity for vascular neurologists to play an ﬂow. Further cadaveric work was done in collaboration with active role in the procedural aspects of diagnosis and man- Almeida Dias and Almeida Lima to understand the radioana- agement of cerebrovascular diseases. However, the above- tomical appearances of cerebral arteries as described in his mentioned description appears to oversimplify the history paper in Journal de Radiologie in 1927. Subsequently, of interventional neurology, which includes a complex chain Dr. Moniz tried to puncture the internal carotid artery in of events since 1927. Dr. Qureshi at the Interventional humans using 0.5–0.6 mm needles at the point of entry into Section of American Academy of Neurology (AAN) in 2006 the carotid oriﬁce without success. He starting using the land- remarked that “the history of interventional neurology has marks formed by the sternomastoid, digastric, and omohyoid been a saga of unwavering determination and unparalleled muscles to access the artery under direct exposure. The ﬁrst six comradeship. What continues to bind us together as a com- patients were injected with sodium bromide, but the last munity is the sense of pride. Pride in our heritage of neurol- patient died 8 hours after the procedure due to a stroke. ogy, pride in the sacriﬁces we made, pride in standing side by Dr. Moniz changed the injections to sodium iodide injection side, and ﬁnally pride in our vision of the future.” This (22%–25%) in the next four patients, one of whom was not chapter summarizes the events in a chronological order and injected because of puncturing a bad artery. The ﬁnal case of a captures the political and academic aspects of change and 20-year-old boy produced a satisfactory result with adequate evolution over the last 80 years. visualization of intracranial arteries. In 1931, Dr. Moniz Textbook of Interventional Neurology, ed. Adnan I. Qureshi. Published by Cambridge University Press. # Cambridge University Press 2011. 1 Chapter 1: History of interventional neurology presented his results at the First International Neurological Norway in 1964. Subsequently, Amundsen’ arrived at Univer- Congress in Bern. He subsequently published his book Diag- sity of California at San Francisco, CA in 1965, to start teach- nostic des tomeurs cerebrales et epreuve de l’encephalographie ing trainees in neuroradiology his technique in the United arterielle in 1931 that described his experience with the ﬁrst States.13 A National Institute of Neurological Diseases and 180 cerebral angiograms. The role of neurologists in diagnostic Blindness (NINDB) traineeship in neuroradiology in July imaging was further enhanced by Karl Theodore Dussik, who 1965 involving 11 departments nationally14 ofﬁcially consoli- was a neurologist at Allgemeine Poliklinik (General Polyclinic) dated the neuroradiology based practice of cerebral angiog- and University of Vienna Medical School. He was the ﬁrst to raphy. The training grants were continued by the National propose the use of ultrasound as a diagnostic device in a paper Institute of Neurological Disorders and Stroke (NINDS) until he wrote in 1941. He also developed the quartz ultrasound about 1976, at which time they were discontinued along with generator with help from engineers F Seidl and C Reisinger at other fellowship programs emphasizing clinical training.15 the Physics Institute of the University of Vienna. In 1970, Drs. Takahashi and Kawanami16 reported the results of 422 cerebral angiographic examinations using Transition to transfemoral approach femoral artery based catheterization. In 1973, Dr. Vitek reported the results for 2000 consecutive examinations17 and and exclusion of neurology in 1976, Drs. Bradac and Simon reported upon 965 examin- The next two decades witnessed more emphasis on accessing ations. All three reports suggested that selective angiography of the arteries through percutaneous puncture using needle- the carotid and vertebral arteries by the femoral route was assisted small diameter cannulas followed by advancement of superior to direct puncture of the vessels in the neck and to catheters to sites distant to the point of entry. The changing retrograde brachial angiography.18 Several reports were subse- patterns also resulted in a movement which would eventually quently published with selective angiography of the carotid exclude neurologists from performance of these procedures. In and vertebral arteries by the femoral route conﬁrming similar 1941, Dr. Farinas5 passed a urethral catheter through a trocar ﬁndings.19 By the early 1970s, cerebral angiography through inserted in the exposed femoral artery and advanced it into the direct carotid puncture by neurologists was an obsolete aorta. In 1947, Dr. Radner6 performed angiography of the practice. vertebral artery after catheterizing exposed and ligated radial artery. In 1949, Jonsson7 from Roentgen Diagnostic Depart- ment in Karolinska Sjukuset, Stockholm, Sweden performed a Therapeutic procedures: aneurysm percutaneous puncture of the common carotid artery using a embolization and intra-arterial thrombolysis blunt cannula with an inner sharp needle. The cannula was In 1941, Werner, who was faculty in the Department of directed downwards using a silver thread to inject and visualize Medicine, along with Blakemore, and King20 from Columbia thoracic aorta. In 1953, Dr. Sven Seldinger8 from Roentgen University College of Physicians and Surgeons, the Presbyter- Diagnostic Department in Karolinska Sjukuset, Stockholm, ian Hospital and the Neurological Institute of New York, Sweden described a new technique for acquiring percutaneous inserted silver wires into an intracranial aneurysm by use of vascular access by placing a catheter subsequent to the needle a transorbital approach to prevent rupture by protecting the puncture and therefore establishing a platform for diagnostic susceptible wall of the aneurysm from the stress of pulsatile and therapeutic procedures. In the original 40 arterial cathe- blood ﬂow. They reported a 15-year-old girl who presented to terizations, 37 were performed through a femoral artery punc- Vanderbilt clinic with diplopia, nausea, and vomiting for ture. Three were performed after puncture of the brachial 5 months on September 25, 1936. On April 17, 1937, the artery via the antecubital fossa with subsequent angiography patient was admitted to the Neurological Institute, New York of the subclavian arteries. However, neurological and neuro- with severe headaches. An aneurysm of the right internal surgical services continued to carry out angiography using carotid artery was suspected, based on atrophy of the anterior percutaneous puncture of the common carotid artery, and and posterior clinoid processes and destruction of the lateral serial ﬁlms were made by identical roentgenological techniques and inferior wall of the right optic foramen on skull X-rays. up to the early 1970s.9 Selective angiography of the carotid and A pneumoencephalogram demonstrated displacement of vertebral arteries by the femoral route was introduced into chiasmatic cistern. The patient was treated using a metal clip practice in the early 1960s. These procedures were performed placed in the cervical internal carotid artery, with progressive only by radiologists and competed with angiography using occlusion over the next 5 days. However, the treatment did not percutaneous puncture of the common carotid artery. Hans improve the patient’s symptoms. The patient’s symptoms con- Newton,10 a radiologist, at the Karolinska Hospital, Sweden, tinued to progress with new bruit that could be auscultated started occasionally using the femoral route with subsequent over the right eye, visual loss in the right eye, and pituitary catheterization of the carotid arteries in 1963. Cerebral angi- dysfunction resulting in multiple admissions. Additional liga- ography through the femoral route with subsequent catheter- tions of the right external and superior thyroid arteries and ization of all supra-aortic arteries was described by Norwegian common carotid artery were unsuccessful. On January 21, neuroradiologist, Per Amundsen11,12 at the Ullevål Hospital in 1939, 2 years and 9 months after the ﬁrst symptom, the 2 Chapter 1: History of interventional neurology procedure was carried out as follows:20 “Under procaine by a 2.5 mm embolus at its end could be introduced through a hydrochloride anesthesia an incision was made through the 22 gauge needle in the common carotid arteries of the dogs lateral canthus of the right eye. Anesthetic solution was intro- and subsequently used to catheterize the thoracic aorta. They duced into the orbital tissues. The eye was displaced medially. subsequently demonstrated that a catheter led by an embolus This gave access to the aneurysm, which had eroded the could be maneuvered through the internal carotid and middle posterior orbit. Thirty feet of No. 34 gauge coin silver enam- cerebral arteries in a 33-year-old woman with cerebral arterio- eled wire was introduced into the aneurysm through a special venous malformation. A subsequent patient was a 51-year-old needle. The velocity of blood ﬂow through the aneurysm was woman with an arteriovenous malformation and a right measured and found to be low. The wire was heated to an internal carotid artery intracranial aneurysm. The investigators average temperature of 80 C. for a total of forty seconds. The were able to introduce ﬂexible Silastic tubing with an enlarged aneurysm no longer bled when the needle was cleared at the inﬂatable tip and maneuver the catheter to the neck of the conclusion of the operation.” However, there was progressive aneurysm using Polaroid ﬁlms. The balloon was deﬂated and diminution of the vision of the left eye after the procedure. the catheter was withdrawn with brief occlusion in the common In 1958, Sussmann and Fitch21 from the Division of carotid artery to induce ﬂow reversal. The technique was tested Neurosurgery at Muhlenberg Hospital in Plainﬁeld, New in the third patient with a ruptured intracranial aneurysm. Jersey reported the results of slow intravenous infusion of In 1959, Fedor Andreevitch Serbinenko who was a neuro- ﬁbrinolysin in three patients with hemiplegia. The site of surgeon in N.N. Burdenko Neurosurgery Institute in Moscow, occlusion of the cerebral vessels was located in each patient Russia, organized a small laboratory to design a balloon cath- by angiography. The ﬁrst patient was admitted to the hospital eter using materials including polyvinyl chloride, polyethylene, on September 6, 1957, because of the abrupt appearance of nylon materials, silicone, and latex. He had been performing hemiplegia of the right side and inability to speak. Cerebral cerebral angiography through direct carotid punctures since angiography on the sixth day of admission demonstrated no 1954 at the institute. On February 8, 1964, the ﬁrst selective ﬁlling of the internal carotid artery beyond the bifurcation of external carotid angiogram in a patient was performed with the common carotid artery. On the same day, 50 000 units of the assistance of temporary internal carotid balloon occlu- ﬁbrinolysin were given intravenously over a 3-hour period. sion.23,24 Serbinenko extended his work to permanent thera- Simultaneously, 25 000 units in 100 ml3 were given after peutic occlusion of cervical and intracranial arteries. The ﬁrst 1 hour, over a 15-minute period, into the left carotid artery. such reported vessel occlusion was performed on April 24, This was repeated on 3 of the next 4 days. A second left carotid 1970 by Serbinenko,24 to sacriﬁce an internal carotid artery angiogram taken 10 days after admission showed an incom- and treat a carotid cavernous ﬁstula. plete 2 cm column of dye in the proximal internal carotid Simultaneous work by Dr. G. Debrun from Serv Neuro- artery. An Additional 75 000 units of ﬁbrinolysin were given radiol, Hop-Henri-Mondor, Creteil, Paris, France documented daily, intravenously, over a 2-hour period for the following the use of inﬂatable detachable balloons to obliterate experi- 6 days. Another angiogram after 18 days of admission demon- mental carotid jugular ﬁstulas and aneurysms in dogs.25 The strated some improvement in ﬁlling of the left internal carotid technique was then applied in a patient with vertebral artery artery. In another case, the angiogram demonstrated no ﬁlling ﬁstula. He subsequently reported the results of intravascular of the middle cerebral arteries before treatment, while on the detachable balloons in 17 post-traumatic carotid-cavernous eighth day after beginning treatment good ﬁlling of the middle sinus ﬁstulas and 14 intracranial aneurysms.26 By 1987, cerebral arteries was obtained. This patient showed the most Jungreis and colleagues showed that catheters can be advanced favorable results, which could be attributed to starting treat- and maneuvered in the intracranial circulation using steereable ment within 6 hours after the onset of symptoms. No compli- microguidewire to the extent that catheterization of intracra- cations were observed related to the diagnostic angiography or nial arteries was no longer dependent upon the use of ﬂow- to the administration of ﬁbrinolysin in any of these patients. directed catheters.27 In 1991, Dr. Guido Guglielmi from the Department of Neurological Sciences, University of Rome Medical School, Rome, Italy and his colleagues from the Entering the intracranial circulation Department of Radiological Sciences, Endovascular Therapy, In 1963, Drs. Luessenhop and Velasquez22 from the Division University of California Medical Center, Los Angeles, of Neurosurgery at Georgetown University Hospital, Washing- California reported the use of a soft detachable platinum coil ton, DC reported the results of manipulation of catheters and delivered through a microcatheter to treat experimental saccu- emboli within the intracranial arteries. The initial experiments lar aneurysms created on the common carotid artery of swine. comprised testing various existing improvised plastic and The detachable platinum coil was soldered to a stainless steel rubber catheters within glass models of internal carotid artery. delivery guidewire and manufactured by Target Therapeutics, The catheters with optimal performance (particularly those San Jose, California. Thrombosis occurred because of the with ﬂexible tips) were successfully manipulated to the ter- attraction of negatively charged white blood cells, red blood minal segment of the internal carotid artery in cadavers. The cells, platelets, and ﬁbrinogen to the positively charged plat- investigators found that a ﬂow-directed Silastic tube directed inum coil positioned within the aneurysm.28 The investigators 3 Chapter 1: History of interventional neurology reported the results of using electrically detachable coils intro- duced via an endovascular approach in 15 patients with intra- cranial saccular aneurysms. Thrombosis of the aneurysm (70% to 100%) was achieved in all 15 patients, with preservation of the parent artery in 14 patients.29 Advancements in image acquisition Concomitant advancement in image acquisition promoted the possibility of real time imaging of catheters and device manipulations. Initially, images were obtained on a manual- pull or a power-driven (Sanchez Perez) ﬁlm changer when cerebral angiography was performed using common carotid artery injections. Three or four ﬁlm hard copies were obtained, and separate injections were required for each plane. In the 1960s, a serial roll ﬁlm changer was used at the Neurological Institute at Columbia Presbyterian in New York, which Fig. 1.1. Drs. Gomez (right) and Qureshi (left) share the podium in 2007. allowed multiple images to be acquired rapidly, usually two per second for 3 seconds and then one per second for 6 seconds.30 In 1979, Charles Mistretta invented the “digital integration of stroke neurologists in all aspects of care includ- vascular imaging” (DVI) technique that is now generally ing evaluation, endovascular treatment, and post-procedural known as digital subtraction angiography (DSA). The subtrac- care. Subsequently, several diagnostic and interventional pro- tion of an image recorded without the use of contrast medium, cedures were performed by Dr. Gomez in the cardiac cathe- and one with contrast medium, created a subtracted image that terization laboratory at St. Louis University until July 1994. only demonstrated the contrast medium opaciﬁcation.31,32 Later, a change in leadership in the medical school led to Sherry and colleagues in 1983 designed a system incorpor- circumstances that resulted in Dr. Gomez moving to ating continuous recursive digital video ﬁltration, allowing the University of Alabama. operator to view a subtracted ﬂuoroscopic image of each The Department of Neurology under the leadership of control angiographic sequence in real time.33,34 Dr. John N. Whitaker, who was Chairman of Neurology and President of the Health Services Foundation, provided Modern era of interventional neurology Dr. Gomez with the opportunity to start another neurointer- The era of modern interventional neurology started with ventional program in collaboration with interventional cardi- Dr. Gomez and his colleagues. In 1991, Dr. Camilo ologists at University of Alabama. The program was initiated R. Gomez was an Associate Professor at St. Louis University, on March 1, 1995 and Dr. Gomez started performing proced- St. Louis, Missouri (Fig. 1.1). He along with Dr. Mark Malkoff ures in the cardiac catheterization laboratory. He was also able had set up an interventional protocol for treatment of acute to build strong relationships with Dr. Jay S. Yadav, who was an ischemic stroke. Dr. Gomez had just returned from a confer- interventional cardiology fellow and Dr. Gary S Roubin, who ence in Argentina where he had met with Dr. Vinuela and had was a leading interventional cardiologist. Dr. Yadav had a productive and motivating discussion about the role of already completed a residency in neurology and fellowship in neurologists in interventional neuroradiology. Subsequently, neuroimaging. Dr. Gomez was visiting Argentina for a meet- Dr. Gomez, with the support of Chairman of Neurology, John ing when he met with Dr. Marco Zenteno from Mexico. B. Selhorst, MD at the Department of Neurology and Souers Dr. Gomez started visiting the Comprehensive Stroke Center, Stroke Institute, St. Louis University School of Medicine, Hospital Angeles del Pedregal, Department of Neurological St. Louis, Missouri, started performing neurointerventional Endovascular Therapy, Instituto Nacional de Neurología y procedures in collaboration with the Head of interventional Neurocirugía, Mexico City, Mexico (National Institute of cardiology, Morton J. Kern MD. The ﬁrst procedure was Neurology and Neurosurgery and Hospital LA at Mexico City) performed by Dr. Gomez in the cardiac catheterization labora- several times a year and performed interventional procedures tory in December 1993. Drs. Gomez and Malkoff successfully with Dr. Zenteno.36 Dr. Morgan Cambell joined Dr. Gomez at incorporated acute response team or “Code Stroke”35 and the University of Alabama as his ﬁrst fellow for a 3-year neurocritical care as essential components of management of fellowship in 1996, which included a combination of vascular patients undergoing neurointerventional procedures. They neurology, neurocritical care, and neurointerventional successfully connected all pagers of stroke team members to procedures. a common access number and instructed the emergency Dr. Adnan I. Qureshi (Fig. 1.1) was a neurology resident at department staff to activate that number immediately upon Emory University in Atlanta, GA in 1994. Dr. Qureshi in 1996 arrival of a stroke patient (Code Stroke). This step allowed the joined a 2-year fellowship in neurocritical care at Johns 4 Chapter 1: History of interventional neurology Hopkins Medical Institutions with the incorporation of some aspects of neuroradiology training within the fellowship. Dr. Qureshi subsequently joined the endovascular neurosurgi- cal fellowship at University at Buffalo, State University of New York in July 1998. He was one of the ﬁrst neurologists along with Edgard Pereira MD to join a formal fellowship program in neurointerventional procedures. The program at University of Buffalo was led by the Chairman of Neurosur- gery, Dr. L. Nelson Hopkins, who was one of the most immi- nent neurosurgeons and considered to be the founder of the modern discipline of endovascular neurosurgery. Drs. Lee R. Guterman (neurosurgeon) and Ajay Wakhloo (neuroradiol- ogist) were both well-reputed neurointerventionalists and formed the other faculty in the program. Dr. Qureshi had an opportunity to train with other neurosurgical fellows such as Drs. Lanzino, Fessler, Ringer, and Lopez, who all subsequently gained prominence in the ﬁeld. His training included a wide spectrum of endovascular procedures for acute ischemic stroke, extra- and intracranial stent placement, and embolization of arteriovenous malformations and aneurysms. Dr. Qureshi worked diligently to incorporate academic research within the program at the University of Buffalo. When Dr. Qureshi completed his fellowship in June 2000, he was invited to stay as faculty in the Department of Neurosurgery and trained several neurosurgery fellows during his two and half years at the University of Buffalo. He also developed an angiographic classiﬁcation scheme for assessing initial severity of arterial occlusion in patients with acute ischemic stroke.37 The classiﬁcation scheme has been validated at multiple institutions since its ﬁrst description and is currently referred to as the “Qureshi grading scheme.”38,39 In December 2002, Dr. Qureshi joined the University of Medicine and Dentistry of New Jersey, Newark, as a Professor Fig. 1.2. The Minnesota Stroke Initiative team in 2007. of Neurology and Director of the Cerebrovascular Program on the invitation of Patrick Pullicino MD, who was Chairman of Neurology and Neurosciences at that time. An interven- In November 2006, Dr. Qureshi joined the University of tional neurology training program was simultaneously initi- Minnesota in Minneapolis, Minnesota as a Professor of ated, with Drs. Kirmani and Xavier starting as the ﬁrst fellows Neurology, Neurosurgery, and Radiology and Executive Dir- in the program. In 2004, Nazli Janjua MD joined the pro- ector of the Minnesota Stroke Initiative.40 An endovascular gram, becoming one of the ﬁrst women to enter interven- surgical neuroradiology fellowship was initiated (Fig. 1.2). tional neurology. Dr. Qureshi also received an RO-1 grant as Drs. Georgiadis, Shah, and Suri formed the ﬁrst group of principal investigator from the National Institutes of Health fellows in the newly started program. The ACGME in June in 2004, starting a track of extramural funded research by 2000 had ofﬁcially approved the Guidelines for Training in interventional neurologists. The Zeenat Qureshi Stroke endovascular surgical neuroradiology. Subsequently, the pro- Research Center was initiated in 2004. Since its inauguration, gram requirements for neurology were approved by the the center has led the way in cutting-edge research in epi- ACGME in May 2003. On January 1, 200841, the criterion demiology, clinical trials, and basic research pertaining to for program directorship was modiﬁed to include physicians cerebrovascular diseases. Zeenat Qureshi Stroke Research with current certiﬁcation in the specialty by the American Center was transferred to the University of Minnesota in Board of Psychiatry and Neurology. In anticipation of this 2006. In 2007, the research center was ranked in the top change, an application was submitted to the Neurosurgery 20 academic facilities for conducting biomedical research Residency Review Committee at ACGME to request formal selected from hundreds of institutions representing several accreditation of the endovascular surgical neuroradiology fel- disciplines of biological sciences in the United States by The lowship at the University of Minnesota. The application was Scientist. Teaching, mentoring, and policies were ranked as subsequently forwarded to a special committee of the Neurol- the strengths of the center. ogy Residency Review Committee with members from the 5 Chapter 1: History of interventional neurology Fig. 1.3. Dr. Shah performing an endovascular procedure with Dr. Gomez (visiting professor) in 2008. Fig. 1.4. A group photograph of several of the interventional neurology trainees in 2007. Neurosurgery and Radiology Residency Review Committees. new techniques during his visit to University of Minnesota). In May 2008, University of Minnesota became the ﬁrst pro- In April 2008, Dr. M. Fareed K. Suri (Fig. 1.2) became the ﬁrst gram to be accredited by the Neurology Residency Review interventional neurologist to receive the extramural K grant Committee and Dr. Qureshi became the ﬁrst neurologist to from National Institutes of Health for career development. be a program director of an accredited endovascular surgical neuroradiology fellowship program. A total of three fellowship positions per year were approved. Over the years, the fellow- Interventional neurology: the national ship program has graduated outstanding fellows, who have and international front received national awards and federal grants. The program Interventional neurology was simultaneously gaining accept- has hosted world renowned visiting professors such as Dr. ance into the organized societies of Neurology (Fig. 1.4). Gomez (Fig. 1.3), who was the President of the American In 1996, an “interventional section” was started within the Society of Neuroimaging (seen in the picture teaching fellows American Academy of Neurology. The section was chaired 6 Chapter 1: History of interventional neurology (Vice-President), Taylor (Secretary), and Shah (Treasurer) as the ﬁrst ofﬁce holders. The society started coordinating the efforts of interventional neurology groups within and outside the United States. Collaboration also started between professional organiza- tions of various specialties. The Neurovascular Coalition was formed in November 2004, led by John J. Connors, III, MD as the ﬁrst Immediate Past President of the American Society of Interventional and Therapeutic Neuroradiology to ensure excellence in medical education, training, and research related to vascular conditions affecting the brain and thus promote high-quality patient care. The coalition members included the American Academy of Neurology, American Fig. 1.5. Drs. Jovin (left) and Qureshi (right), Associate Editors of the Journal Association of Neurological Surgeons, American Society of of Neuroimaging, share the podium in 2007. Interventional and Therapeutic Neuroradiology, American Society of Neuroradiology, Congress of Neurological Sur- geons. AANS/CNS Cerebrovascular Section, and Society of by prominent interventional neurologists over the years Interventional Radiology. The coalition prepared a multi- including Kori (1996–1998), Gomez (1998–2000), Yadav society landmark consensus document42 entitled “Training, (2000–2002), Hauser (2002–2004), Qureshi (2004–2006), and competency, and credentialing standards for diagnostic cer- Pereira (2006–2008) leading to unprecedented growth. The vicocerebral angiography, carotid stent placement, and cere- interventional neurology ﬁeld gained prominence in the brovascular intervention” that deﬁnes minimum standards programs of the annual meeting of the American Academy for the training, knowledge, and experience necessary to of Neurology and American Society of Neuroimaging. perform carotid stent placement and other diagnostic and Dr. Gomez initiated the “Endovascular Therapy and Critical therapeutic cerebrovascular procedures. This was followed by Care Course” and Dr. Suarez initiated the “Interventional another document “Qualiﬁcation requirements for perform- Treatment of Acute Ischemic Stroke” course at the 55th ing neuro-interventional procedures: A report of the Practice Annual Meeting of the American Academy of Neurology, Guidelines Committee of the American Society of Neuroima- Honolulu, Hawaii, in March 2003. In January 2004, ging and the Society of Vascular and Interventional Neurol- Dr. Qureshi initiated a course on angiography and interven- ogy” that was authored by Qureshi, Abou-Chebl, and Jovin.43 tional neurology at the 27th Annual Meeting of the American The document summarized the existing data derived from Society of Neuroimaging, in Phoenix, AZ. In April 2006, regulatory bodies, professional organizations, and clinical Dr. Qureshi initiated the half-day course on “Update on trials with direct pertinence to indications and qualiﬁcations Endovascular Treatment of Cerebrovascular Disease” at the required for performing neurointerventional procedures and 58th Annual Meeting of the American Academy of Neurol- provided recommendations regarding qualiﬁcations required ogy, San Diego, CA. The interventional section of the Ameri- for performing individual neurointerventional procedures. can Academy of Neurology (AAN) had 267 active members Such efforts have led to an increased recognition of inter- by 2006. A plenary session dedicated to interventional neurol- ventional neurology as a subspecialty of neurology over the ogy was the highlight of the American Society of Neuroima- last decade. ging Annual Meeting in Miami in January 2007. The Journal of Neuroimaging, the ofﬁcial journal of the Society of Neuro- imaging started an interventional section in 2007 with The future Drs. Qureshi and Jovin (Fig. 1.5) as Associate Editors dedi- With sights set on excellence, interventional neurology will cated to the section. Drs. Qureshi and Georgiadis edited the continue to grow and prosper. The enduring legacy of any Atlas of Interventional Neurology that was published by effort or journey is not what we have achieved, but what we Demos Medical Publishing, New York, NY, 2008 becoming have become as a consequence. In the address to the interven- the ﬁrst textbook of interventional neurology. In January tional section at the American Academy of Neurology 59th 2008, the Journal of Vascular and Interventional Neurology Annual Meeting, Boston, MA, on May 2007, Dr. Qureshi was published starting the ﬁrst periodical for interventional summarized the evolution of Interventional Neurologist as neurology. Interventional neurology was also gaining recog- follows: “Any organization that commits to self-sacriﬁce for nition in other countries and was one of the highlights of the greater good has already taken the ﬁrst step to greatness. the 45th Turkish Neurology Congress, Ulusal Noroloji The ramiﬁcations of this commitment will shake any organiza- Kongresi, Antalya, Turkey, 10–15 Kasim, 2009. In November tion to the core but their desire to seek greatness will bond 2009, the International Society of Interventional Neurology them together into an eternal legacy that will last longer than was started, with Drs. Qureshi (President), Pereira their mortal existence.” 7 Chapter 1: History of interventional neurology References Acta Neurol Scand 1967; Suppl. 31:115. Am J Neuroradiol 2001;22:584–9. cerebral vascular lesions. J Neurosurg 1978;49:635–49. 1. Qureshi AI. Endovascular treatment of cerebrovascular diseases and 14. Kieffer SA. Harold O. Peterson, MD: a 27. Jungreis CA, Berenstein A, Choi IS. intracranial neoplasms. Lancet life in neuroradiology. AJNR Am Use of an open-ended guidewire: 2004;363:804–13. J Neuroradiol 1993;14:1427–35. steerable microguidewire assembly system in surgical neuroangiographic 2. Kori SH. Interventional neurology: a 15. Taveras JM. Development of the ﬁrst procedures. Am J Neuroradiol subspecialty whose time has come. fellowship training program in 1987;8:237–41. Neurology 1993;43:2395–9. neuroradiology in North America. Am J Neuroradiol 1991;12:587–90. 28. Guglielmi G, Vinuela F, Sepetka I, 3. Wilkins Rh ME. Wilkins Rh. Moniz E. Macellari V. Electrothrombosis of Neurosurgical classic. Xvi. Arterial 16. Takahashi M, Kawanami H. Femoral saccular aneurysms via endovascular encephalography. Its importance in the catheter techniques in cerebral approach. Part 1: Electrochemical basis, localization of cerebral tumors. angiography – an analysis of 422 technique, and experimental results. J Neurosurg 1964;21:144–56. examinations. Br J Radiol 1970;43: J Neurosurg 1991;75:1–7. 771–5. 4. Moniz E. L’encephalographie arterielle, 29. Guglielmi G, Vinuela F, Dion J, son importance dans la localisation des 17. Vitek JJ. Femoro-cerebral angiography: Duckwiler G. Electrothrombosis of tumeurs cerebrales. Revue Neurologique analysis of 2,000 consecutive saccular aneurysms via endovascular 1927;2:72–89. examinations, special emphasis on approach. Part 2: Preliminary clinical 5. Farinas PL. A new technique for the carotid arteries catheterization in older experience. J Neurosurg 1991;75:8–14. arteriographic examination of the patients. Am J Roentgenol Radium Ther Nucl Med 1973;118:633–47. 30. Leeds NE, Kieffer SA. Evolution of abdominal aorta and its branches. Am diagnostic neuroradiology from 1904 to J Roentgenol 1941;46. 18. Bradac GB, Simon RS. [Routine use of a 1999. Radiology 2000;217:309–18. 6. Radner S. Intracranial angiography via catheter technique for cerebral angiography (965 examinations) 31. Ergun DL, Mistretta CA, Kruger RA, the vertebral artery; preliminary report Riederer SJ, Shaw CG, Carbone DP. of a new technique. Acta Radiol (author’s transl)]. Rofo 1976;125:66–9. A hybrid computerized ﬂuoroscopy 1947;28:838–42. 19. Caresano A, Del Favero C, Crivelli G, technique for noninvasive 7. Jonsson G. Thoracic aortography Tenti L, Bianchi M. [Selective cardiovascular imaging. Radiology by means of a cannula inserted arteriography of the carotid and 1979;132:739–42. percutaneously into the common vertebral arteries by the femoral route: review of 225 patients (author’s transl)]. 32. Brant-Zawadzki M, Gould R, Norman carotid artery. Acta Radiol 1949;31: D, Newton TH, Lane B. Digital 376–86. Radiol Med 1977;63:225–32. subtraction cerebral angiography by 8. Seldinger SI. Catheter replacement of 20. Werner SCBA, King BG. Aneurysm of intraarterial injection: comparison with the needle in percutaneous the internal carotid artery within the conventional angiography. AJR Am arteriography; a new technique. Acta skull: wiring and electrothermic J Roentgenol 1983;140:347–53. Radiol 1953;39:368–76. coagulation. JAMA 1941;116:578–82. 33. Sherry RG, Anderson RE, Kruger RA, 9. Fletcher TM, Taveras JM, Pool JL. 21. Sussman BJFT. Thrombolysis with Nelson JA. Real-time digital subtraction Cerebral vasospasm in angiography for ﬁbrinolysis in cerebral arterial angiography for therapeutic intracranial aneurysms. Incidence and occlusion. JAMA 1958;167:1705–9. neuroradiologic procedures. Am signiﬁcance in one hundred consecutive 22. Luessenhop AJ, Velasquez AC. J Neuroradiol 1983;4:1171–3. angiograms. Arch Neurol 1959;1:38–47. Observations on the tolerance of the 34. Strother CM. Interventional 10. Newton TH, Kramer RA. Clinical used intracranial arteries to catheterization. neuroradiology. Am J Neuroradiol of selective external carotid J Neurosurg 1964;21:85–91. 2000;21:19–24. arteriography. Am J Roentgenol Radium 23. Serbinenko FA. [Catheterization and 35. Gomez CR, Malkoff MD, Sauer CM, Ther Nucl Med 1966;97:458–72. occlusion of major cerebral vessels and Tulyapronchote R, Burch CM, Banet 11. Amundsen P, Dietrichson P, Enge I, prospects for the development of GA. Code stroke. An attempt to shorten Williamson R. Cerebral angiography by vascular neurosurgery]. Vopr Neirokhir inhospital therapeutic delays. Stroke catheterization–complications and side 1971;35:17–27. 1994;25:1920–3. effects. Acta Radiol Ther Phys Biol 24. Serbinenko FA. Balloon catheterization 36. Zenteno MA, Murillo-Bonilla LM, 1963;1:164–72. and occlusion of major cerebral vessels. Guinto G, et al. Sole stenting bypass 12. Amundsen P, Dugstad G, Noyes W. J Neurosurg 1974;41:125–45. for the treatment of vertebral artery Cerebral angiography via the femoral 25. Debrun G, Lacour P, Caron JP, Hurth aneurysms: technical case report. artery with particular reference to M, Comoy J, Keravel Y. Inﬂatable Neurosurgery 2005;57:E208; cerebrovascular disease. Acta Neurol and released balloon technique discussion E. Scand 1967;43:Suppl 31:115. experimentation in dog – application in 37. Qureshi AI. New grading system for 13. Rosenbaum AE, Eldevik OP, Mani JR, man. Neuroradiology 1975;9:267–71. angiographic evaluation of arterial Pollock AJ, Mani RL, Gabrielsen TO. In 26. Debrun G, Lacour P, Caron JP, occlusions and recanalization response re: Amundsen P. Cerebral angiography Hurth M, Comoy J, Keravel Y. to intra-arterial thrombolysis in acute via the femoral artery with particular Detachable balloon and calibrated-leak ischemic stroke. Neurosurgery reference to cerebrovascular disease. balloon techniques in the treatment of 2002;50:1405–14; discussion 14–5. 8 Chapter 1: History of interventional neurology 38. Mohammad YM, Christoforidis GA, program building, procedural types, Surgeons, the American Society of Bourekas EC, Slivka AP. Qureshi and outcomes. J Neuroimaging Interventional and Therapeutic grading scheme predicts subsequent 2009;19:72–9. Neuroradiology, the American Society volume of brain infarction following 41. Program requirements for residency of Neuroradiology, the Congress of intra-arterial thrombolysis in patients education in endovascular surgical Neurological Surgeons, the AANS/CNS with acute anterior circulation ischemic neuroradiology (Accessed last Cerebrovascular Section, and the stroke. J Neuroimaging 2008;18:262–7. accessed on September 12, 2007, at, Society of Interventional Radiology. 39. Mohammad Y, Xavier AR, www.acgme.org/acWebsite/RRC_160/ Neurology 2005;64:190–8. Christoforidis G, Bourekas E, Slivka A. 160_prIndex.asp.) 43. Qureshi AI, Abou-Chebl A, Jovin TG. Qureshi grading scheme for 42. Connors JJ, 3rd, Sacks D, Furlan AJ, Qualiﬁcation requirements for angiographic occlusions strongly et al. Training, competency, and performing neurointerventional correlates with the initial severity and credentialing standards for diagnostic procedures: a Report of the Practice in-hospital outcome of acute ischemic cervicocerebral angiography, carotid Guidelines Committee of the American stroke. J Neuroimaging 2004;14:235–41. stenting, and cerebrovascular Society of Neuroimaging and the 40. Qureshi AI, Janardhan V, Memon MZ, intervention: a joint statement from the Society of Vascular and Interventional et al. Initial experience in establishing American Academy of Neurology, the Neurology. J Neuroimaging an academic neuroendovascular service: American Association of Neurological 2008;18:433–47. 9 Chapter 2 Diagnostic cerebral angiography Adnan I. Qureshi and Ameer E. Hassan Cerebral angiography is a procedure by which the intracranial procedures to guide patient selection, planning technical and extracranial head and neck circulation is evaluated.1 It aspects of the procedure, and monitoring the results of these entails the placement of a catheter selectively into extracranial procedures. Another reason for increased rates of angiography cerebral vessels using ﬂuoroscopic guidance, followed by con- may be found in recent data suggesting that, in practice, the trast material injection and image acquisition to delineate reliability of non-invasive studies may be inferior to angiog- anatomy and abnormalities. raphy for appropriate guidance in patient selection.7,8 Utilization of cerebral angiography Recommended indications from The use of non-invasive cerebrovascular imaging was increased while the use of cerebral angiography has declined professional organizations since 1985.2 A prominent decrease was seen in pre-procedure The practice guidelines from the Stroke Council of the American cerebral angiograms among patients undergoing carotid Heart Association recommend cerebral angiography for imaging endarterectomy.3,4 According to the most recent Medicare in transient ischemic attacks and acute stroke under selected data show that, in 2002, at least 92 000 cervicocerebral arter- conditions. Patients with retinal ischemic events or transient iograms (Current Procedural Terminology codes 75680 and ischemic attacks are deemed to be candidates for cerebral angi- 75676, respectively, for bilateral or unilateral cervical carotid ography when there is reasonable evidence of carotid atheroscler- arteriography) were performed, compared with 109 000 per- otic disease that warrants consideration of endarterectomy. formed 5 years previously. However, in a recent study we Evidence of luminal reduction greater than or equal to 70% on found evidence that the overall use of cerebral angiography ultrasound, magnetic resonance angiography, or computed increased between 1990 and 1991 and 2000 and 2001. We used tomographic arteriography, is usually a strong indication for data from the Nationwide Inpatient Sample, the largest cerebral angiography in symptomatic patients who are candi- all-payer inpatient care database in the United States.5 dates for endarterectomy. Some stenotic lesions measured at 50% International Classiﬁcation of Disease, 9th Revision, Clinical to 69% by non-invasive techniques may show luminal reduction Modiﬁcation primary diagnosis codes were used to identify the greater than or equal to 70% on cerebral angiography, making patients admitted with stroke and stroke subtypes and second- them eligible for endarterectomy. Conversely, occlusion on non- ary codes to identify those with stroke-associated complica- invasive testing may correlate with a residual hairline lumen on tions and related procedures. In a 2-year period, 1990 to 1991, cerebral angiography in as many as 9% of patients (Class II, see there were 1 736 352 admissions for cerebrovascular diseases, Table 2.1). Cerebral angiography also is required to evaluate and in another 2-year period, 2000 to 2001, there were intracranial stenosis or occlusion. Selective subclavian and/or 1 958 018 admissions. Cerebral angiography during hospital- vertebral cerebral angiography remains the reference procedure ization was performed in 126 572 (7.3%) patients in 1990–1991 for imaging of vessels in vertebrobasilar occlusive disease. The and in 161 256 (8.3%) patients in 2000–2001. The rate of outline of arteries that are diseased, whether from stenotic or cerebral angiography increased most prominently for patients occlusive atherosclerosis, dissection, or arterial dysplasias, can be with subarachnoid hemorrhage, from 32% in 1990–1991 to characterized more accurately than by current magnetic reson- 54% in 2000–2001. The recent increase in utilization during ance angiography techniques. Selective cerebral angiography is hospitalization is attributed to the increase in neurointerven- the recommended procedure for diagnosis of cerebral aneurysm tional procedures among patients with cerebrovascular dis- in patients with subarachnoid hemorrhage (type A). Cerebral eases.6 Interventional angiography is cerebral angiography angiography is recommended to detect beading, stenosis, or that is performed either prior to or during neurointerventional aneurysm, particularly in medium sized and small cerebral Textbook of Interventional Neurology, ed. Adnan I. Qureshi. Published by Cambridge University Press. # Cambridge University Press 2011. 10 Chapter 2: Diagnostic cerebral angiography Table 2.1. Criteria for grading the quality of evidence ratings for diagnostic vessels affected by vasculitis (type C). Where magnetic resonance tests by the Stroke Council, American Heart Association** imaging and magnetic resonance angiography are not available, Class I Evidence provided by one or more well-designed cerebral angiography is a diagnostic option to be used independ- clinical studies of a diverse population using a ently or in combination with other tests for diagnosis of deep gold standard reference test in a blinded vein, cortical vein, or dural sinus thrombosis (type C). Cerebral evaluation appropriate for the proposed angiography may be done if the diagnosis from magnetic reson- diagnostic application. ance imaging/magnetic resonance angiography is unclear and Class II Evidence provided by one or more clinical studies there is strong suspicion of arterial dissection (type C). Cerebral of a restricted population using a reference test in angiography also continues to be the “gold standard” in the a blinded evaluation of diagnostic accuracy. diagnostic evaluation of unruptured intracranial aneurysms10 Class III Evidence provided by expert opinion, non- and provides the most information about small perforating randomized historical controls, or observation(s) vessels by producing higher-resolution images than other from case series. imaging modalities. Strength of recommendations rating The Brain Attack Coalition recommends the following regarding cerebral angiography (grade 1A).11 Cerebral angiog- Type A Strong positive recommendation, based on Class I raphy is the gold standard for the detection and characterization evidence or overwhelming Class II evidence when of cerebral aneurysms, arteriovenous malformations, and arter- circumstances preclude randomized clinical trials. iovenous ﬁstulas, and for measuring the exact degree of stenosis Type B Positive recommendation, based on Class II in extracranial and intracranial arteries (grade IA). It is the evidence. procedure of choice for evaluating the third- and fourth-order Type C Positive recommendation, based on strong intracranial branches to make a diagnosis of central nervous consensus of Class III evidence. system vasculitis. Because of the emergent nature of some of the stroke types discussed above, cerebral angiography must be Type D Negative recommendation, based on inconclusive or conﬂicting Class II evidence. available at a comprehensive stroke center on a 24/7 basis, with support personnel available to come in from home for a pro- Type E Strong negative recommendation, based on cedure within 60 minutes of being called. A comprehensive evidence of ineffectiveness or lack of efﬁcacy, stroke center must demonstrate a peri-procedure stroke and based on Class I or Class II evidence. death rate of less than 1% and an overall serious complication Classiﬁcation of recommendations rate of less than or equal to 2% for cerebral angiography. Class I Conditions for which there is evidence for and/or The Quality Improvement Guidelines12 for Adult Diagnos- general agreement that the procedure or tic Neuroangiography from the Society of Cardiovascular and treatment is useful and effective. Interventional Radiology, the American Society of Interven- tional and Therapeutic Neuroradiology, and the American Class II Conditions for which there is conﬂicting evidence and/or a divergence of opinion about the Society of Neuroradiology deﬁned appropriate indications for usefulness/efﬁcacy of a procedure or treatment. performance of cerebral angiography (see Table 2.2). The threshold for these indications is 99%. When fewer than 99% IIa The weight of evidence or opinion is in favor of of procedures are performed for these indications, the insti- the procedure or treatment. tution should review the process of patient selection. IIb Usefulness/efﬁcacy is less well established by evidence or opinion. Technical aspects of the procedure Class III Conditions for which there is evidence and/or The cerebral angiography is comprised of six steps as outlined general agreement that the procedure or below: treatment is not useful/effective and in some cases may be harmful. Level of evidence Percutaneous access Percutaneous access is secured through two main routes for a Level of Data derived from multiple randomized clinical cerebral angiogram. The femoral artery is the most common evidence A trials. route followed by radial artery access. Brachial and carotid Level of Data derived from a single randomized trial or artery access are rarely used. Femoral artery access requires evidence B non-randomized studies. insertion of an 18 or 19 gage needle in the common femoral Level of Consensus opinion of experts. artery below the inguinal ligament. The inguinal ligament runs evidence C from the anterior superior iliac spine to the pubic tubercle. **Guidelines from the American Heart Association/American Stroke Association The site for percutaneous insertion is determined by one of Stroke Council three methods. The ﬁrst requires manual identiﬁcation of the pubic symphysis and the anterior superior iliac spine to 11 Chapter 2: Diagnostic cerebral angiography Table 2.2. Indications for cerebral angiography: Guidelines of Table 2.3. Various catheters used for cerebral angiography in 150 the Society of Cardiovascular and Interventional Radiology, the American consecutive studies in adult patients Society of Interventional and Therapeutic Neuroradiology, and the American Society of Neuroradiology12 Diagnostic catheters Frequency Indications Single catheter used in study 74 procedures 1. Deﬁne presence/extent of vascular occlusive disease and Multiple catheters used in study 76 procedures thromboembolic phenomena. 4 F vertebral catheter 10 2. Deﬁne etiology of hemorrhage (subarachnoid, 5 F Davis catheter 95 intraventricular, parenchymal, craniofacial). 5 F Simmons II catheter 40 3. Deﬁne presence, location, and anatomy of intracranial aneurysms and vascular malformations. 5 F Simmons I catheter 10 4. Evaluate vasospasm related to subarachnoid hemorrhage. 5 F Headhunter catheter 20 5. Deﬁne presence/extent of trauma to cervicocerebral vessels (e.g., dissection, pseudoaneurysm). Radial artery access is used in patients with difﬁcult fem- 6. Deﬁne vascular supply to tumors. oral artery access usually due to occlusive disease of the femoral and/or iliac arteries. The radial artery may also be 7. Deﬁne presence/extent of vasculitis (infectious, inﬂammatory, preferred for visualization of the right subclavian artery which drug-induced). may be difﬁcult to catheterize in patients with tortuous vessels 8. Diagnose and/or deﬁne congenital or anatomic anomalies through the femoral route. The radial and ulnar arteries supply (e.g., vein of Galen ﬁstula). blood to the musculoskeletal tissue and skin of the hand. 9. Deﬁne presence of venous occlusive disease (e.g., dural sinus In most patients, the ulnar artery can supply both territories cortical, deep). in case of radial artery compromise, through the palmar arch. 10. Outline vascular anatomy for planning and determining the Before considering radial artery access, patients are examined effect of therapeutic measures. to conﬁrm patency of the palmar arch.15 A visual Allen test is performed, for which blanching of the palm subsides within 11. Perform physiologic testing of brain function (e.g., WADA). 7 seconds after release of the ulnar artery, while still compress- ing the radial artery.16 In addition, a Doppler probe is placed determine the position of the inguinal ligament. An imaginary over the expected region of the palmar arch to determine line is drawn between the two anatomic points and femoral whether arterial signal intensity remains present during com- artery pulsation is sought four inches below the line. The second pression of the radial artery.15 Our preferred method requires method uses ﬂuoroscopy to identify the center of the femoral a pulse oximeter placed on the patient’s thumb while the radial bone head and uses the identiﬁed site for palpation. The third artery is compressed, and patency of the palmar arch is con- method requires an ultrasound probe to visualize the common sidered present if a strong waveform remains and the percent- femoral artery and the needle is manipulated under direct age of oxygen saturation remains unchanged. Puncture of the ultrasound guidance. The modiﬁed Seldinger’s technique is radial artery (on the right in most procedures) is performed used which requires needle insertion in the artery, passage of approximately 2 cm cephalad to the radial styloid using a an introducer wire, and introduction of an introducer sheath 21 gauge needle. Immediately after sheath insertion, a mixture over the wire in to the artery.13 Fluoroscopic visualization of the of heparin (5000 IU/ml), verapamil (2.5 mg), lidocaine (2%, direction and location of the introducer wire provides con- 1.0 ml), and nitroglycerin (0.1 mg) is infused through the ﬁrmation of adequate positioning of the wire. introducer sheath to relieve and/or prevent vasospasm.17 Introducer sheaths are available from 4 to 8 French in diameter and are selected based on the requirements of the catheters intended for use. The sheaths are available in 20 cm, Aortic placement and selective catheterization 40 cm, and 80 cm length, and usually the 40 cm or 80 cm sheaths of supra-aortic arteries are reserved for patients with tortuous femoral and iliac vessels. Most diagnostic cerebral angiograms are performed using A randomized trial compared introduction of diagnostic cath- either a 4 or 5 French diagnostic catheter with tapered tip eters through introducer sheaths to direct introduction without and wire braiding for enhanced torque control. For practical sheaths, for cerebral angiography.14 The ease of catheter purposes, ﬁve diagnostic catheters with different conﬁguration manipulation was greater with an introducer sheath and a lower are used for cerebral angiography (see Table 2.3 and Fig. 2.1). incidence of bleeding at the femoral puncture site during the 1) The Pigtail catheter which has ring-shaped multiple side- procedure was observed (2%, versus 36%). Because of bleeding, holes at its distal end for large volume injections with minimal conversion to sheath insertion was necessary in 39% of 421 catheter movement and is used for aortic arch injections or patients in the control group. Therefore, use of arterial sheaths aortograms. 2) The vertebral curve (Davis) catheter (see Fig. 2.2) is recommended for cerebral angiography. with a simple hockey-stick design, normally used for selective 12 Chapter 2: Diagnostic cerebral angiography Fig. 2.2. A Davis catheter in the arch of the aorta with tip turned cephalad to engage supra-aortic vessel origin. Fig. 2.1. Various types of diagnostic catheters used in cerebral angiography: (a) Davis catheter; (b) Simmons II catheter; (c) Simmons I catheter; (d) Headhunter catheter. Fig. 2.3. A constituted Simmons II catheter in the arch of the aorta with tip turned cephalad to engage supra-aortic vessel origin. studies of the carotid or vertebral arteries, but also for innomin- ate and subclavian artery injections. Simmons II catheter (see Fig. 2.3), with a tip that curves back upon the body of the catheter for selection of vessels, is used for older patients with tortuous aortas and/or great vessel origins particularly for selection of the left common carotid, innominate, or left sub- Fig. 2.4. A constituted Simmons I catheter in the arch of aorta with tip turned clavian arteries. The Simmons I catheter (see Fig. 2.4), with a cephalad to engage supra-aortic vessel origin. 13 Chapter 2: Diagnostic cerebral angiography Fig. 2.5. A Headhunter catheter in the arch of aorta with tip turned cephalad to engage supra-aortic vessel origin. tip that curves back upon the body of the catheter once reconsti- tuted, allows for placement in tortuous origins off the arch. Fig. 2.6. The sequence of steps required to constitute the Simmons II catheter in the aorta. Because of the shorter curve (as compared to the Simmons II), the Simmons I catheter is preferred for angiography performed through the radial artery. 5) The Headhunter catheter, which is supra-aortic vessels. Once the origin is engaged, the catheter is cobra-shaped (see Fig. 2.5), has greater stiffness than the above pulled back resulting in the advancement of the catheter mentioned catheters and is used for catheterizing difﬁcult right towards the distal common carotid artery or subclavian artery. subclavian arteries. The catheter may be removed from a selected vessel by push- The diagnostic catheter is advanced over a 0.035 inch wire ing and reforming a curve in the arch or by pulling and with a gentle curve at the distal end that can be manipulated straightening a curve in the arch. from the proximal end of the guidewire. The guidewire is A Headhunter catheter is used for catheterizing a challen- advanced into the abdominal aorta, thoracic aorta, and the ging right subclavian artery. The Headhunter conﬁguration arch of aorta. The diagnostic catheter is then advanced over allows stable placement and manipulation of the catheter in the guidewire into the arch of the aorta. The guidewire is the right innominate artery to allow access to the right sub- withdrawn into the diagnostic catheter and the catheter pulled clavian artery. back with the angulated tip pointed cephalad in a direction A Simmons I catheter may be helpful in circumstances that allows engagement of the origin of the supra-aortic where tortuous proximal segments of the supra-aortic vessels vessels. Once the origin is engaged, the guidewire is advanced may not permit advancing the angulated or Simmons II towards the distal common carotid artery or subclavian artery.

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