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DIGITAL SUBTRACTION ANGIOGRAPHY IN CEREBROVASCULAR DISEASE AND PERSPECTIVE.pptx
- 1. DIGITAL SUBTRACTION ANGIOGRAPHY IN CEREBROVASCULAR DISEASE AND PERSPECTIVE IN DIAGNOSIS DR. DEVASHISH GUPTA
- 2. INTRODUCTION Fluoroscopic technique for visualization of blood vessels (Gold standard) Accurately determine the size and location of vascular lesions, detecting tandem arterial lesions and assessing the collateral circulation Demonstration of vascular anatomy by direct injection of iodinated contrast medium into the vessel. Radioopaque structures (eg. bones) are subtracted digitally from image SIX VESSEL ANGIOGRAPHY 1. Right ICA 2. Left ICA 3. Right ECA 4. Left ECA 5. Right vertebral artery 6. Left vertebral artery
- 3. INDICATIONS 1. Primary vascular disease Vaso-occlusive disease Aneurysm AV malformations Arteriovenous fistula 2. Vascular assessment of tumors 3. Congenital vascular condition 4. Interventional procedures Mechanical thrombectomy Intra- arterial thrombolysis Angioplasty and stenting
- 4. CONTRAINDICATIONS Bleeding diathesis Thrombogenic conditions Skin infections Abnormal renal function Cardiac condition Allergy to iodinated contrast agents Pregnancy Non palpable pulse
- 5. APPROACH TO CASE OF ISCHEMIA INFARCTION
- 6. TECHNIQUE OF DSA Adequate hydration with 4hr fasting prior to procedure Informed consent Sterilisation of site followed by local anesthesia Site of puncture: Right femoral artery using Seldinger technique Inject 2500U heparin (0.5ml) and flush sheath with saline Desired catheter is taken and angiography is started
- 7. TECHNIQUE Location and palpation of femoral artery LA infiltration Arterial Puncture Placement of arterial sheath
- 10. VERTEBRAL ARTERY (AP XRAY)
- 11. VERTEBRAL ARTERY (LATERAL XRAY)
- 12. CEREBRAL VEINS (AP XRAY)
- 13. CEREBRAL VEINS (LATERAL XRAY)
- 14. ACUTE CEREBRAL ISCHEMIA- INFARCTION DSA used as a prelude to intraarterial thrombolysis or mechanical thrombectomy Major vessel occlusion: Interruption of contrast column Abrupt vessel cut off Meniscus sign Tapered or rat tail narrowing Tram track appearance with trickle of contrast around intraluminal thrombus Less common signs: Hyperemia with vascular blush around infracted zone (Luxury perfusion) Early draining veins (AV shunting with contrast appearing in veins draining the infarct while remainder of circulation is in later arterial or early capillary phase)
- 15. ACUTE CEREBRAL ISCHEMIA- INFARCTION Early arterial phase: Abrupt vessel cut off (MCA) and Bare area of devascularised brain
- 16. ACUTE CEREBRAL ISCHEMIA- INFARCTION Retrograde filling of distal MCA branches from collaterals from ACA and PCA
- 17. ACUTE CEREBRAL ISCHEMIA- INFARCTION Capillary phase: Blush in ACA/PCA territory Venous phase: Persistent contrast in MCA branches with Luxury perfusion at bare area
- 18. ACUTE CEREBRAL ISCHEMIA- INFARCTION Complete occlusion of left ICA to level of CCA
- 19. VENOUS INFARCTION DURAL SINUS THROMBOSIS Occluded (non filling) sinus Slow flow with or without clot in adjacent cortical veins Delayed emptying of cortical veins: Hanging in space appearance SUPERFICIAL VEIN THROMBOSIS Thin round or tubular layer of contrast surrounding thrombus DEEP CEREBRAL VENOUS THROMBOSIS Absent opacification of deep venous system
- 21. NON ATHEROSCLEROTIC VASCULOPATHIES Dissection Carotid web Reversible cerebral vasoconstriction syndrome (RCVS) Vasculitis Recreational drug use Moya moya disease Fibromuscular dysplasia (FMD)
- 22. ARTERIAL DISSECTION Pearl-and-string sign Double-lumen sign Short, smooth, tapered occlusion Pseudoaneurysm formation
- 23. CAROTID WEB Focal linear shelf like filling defect along the wall
- 24. RCVS Multifocal narrowing and beaded appearance Near complete resolution at follow up
- 25. MOYA MOYA DISEASE Progressive bilateral stenosis of the distal internal carotid arteries, extending to the proximal ACA and MCA, with development of an extensive collateral (parenchymal, leptomeningeal, and transdural) network at the base of the brain like a cloud or puff of smoke Suzuki’s 6 angiographic stages: (1) stenosis of the carotid fork, (2) appearance of moyamoya vessels at the base of the brain, (3) intensification of moyamoya vessels, (4) minimization of moyamoya vessels, (5) reduction of moyamoya vessels (6) disappearance of moyamoya vessels (collaterals only from external carotid arteries)
- 26. FIBROMUSCULAR DYSPLASIA “String of beads” angiographic appearance
- 27. VASCULITIS TAKAYASU ARTERITIS: Long segment smooth stenosis SLE: Irregular beaded appearance
- 33. REFERENCES Bradley and Daroff’s Neurology in clinical practice 2, 8th edition 2021 Osborne’s brain Imaging, pathology and anatomy, 2nd edition AIIMS MAMC PGI comprehensive textbook of diagnostic radiology Vol 1, 1st edition Peter Fleckenstein Anatomy in diagnostic imaging, 3rd edition McCarty JL, Leung LY, Peterson RB, Sitton CW, Sarraj A, Riascos RF, Brinjikji W. Ischemic infarction in young adults: A review for radiologists. Radiographics. 2019 Oct;39(6):1629-48. Narsinh KH, Kilbride BF, Mueller K, Murph D, Copelan A, Massachi J, Vitt J, Sun CH, Bhat H, Amans MR, Dowd CF. Combined use of X-ray angiography and intraprocedural MRI enables tissue-based decision making regarding revascularization during acute ischemic stroke intervention. Radiology. 2021 Apr;299(1):167. Birenbaum D, Bancroft LW, Felsberg GJ. Imaging in acute stroke. Western Journal of Emergency Medicine. 2011 Feb;12(1):67.
Editor's Notes
- 1: Middle cerebral artery 2: Insular arteries 3: Lateral thalamostriate arteries 4: Ophthalmic artery 5: Internal carotid artery in carotid canal 6: Anterior cerebral artery7: Carotid “syphon”
- 1: Callosomarginal artery 2: Pericallosal artery 3: Middle cerebral artery 4: Frontopolar artery 5: Anterior cerebral artery 6: Ophthalmic artery 7: Carotid “syphon” 8: Internal carotid artery in carotid canal 9: Middle meningeal artery 10: Maxillary artery 11: Insular arteries 12: Middle cerebral artery, parietal branches 13: Anterior choroid artery 14: Posterior cerebral artery 15: Posterior communicating artery 16: Occipital artery
- 1: Posterior cerebral artery 2: Basilar artery 3: Vertebral artery 4: Superior cerebellar arteries 5: Anterior inferior cerebellar arteries 6: Overflow in contralateral vertebral artery 7: Posterior inferior cerebellar arteries (“AICA”) (“PICA”)
- 1: Posterior communicating arteries 2: Basilar artery 3: Vertebral arteries 4: Posterior cerebral arteries 5: Superior cerebellar arteries 6: Anterior inferior cerebellar arteries (“AICA”) 7: Posterior inferior cerebellar artery (PICA)
- 1: Superior sagittal sinus 2: Transverse sinus 3: Superior petrous sinus 4: Bulb of internal jugular vein 5: Internal jugular vein 6: Confluence of sinuses 7: Sigmoid sinus 8: Inferior veins of cerebellar hemisphere 9: Inferior vermis vein 10: Inferior petrous sinus
- 1: Superior sagittal sinus 2: Superior cerebral veins 3: Great cerebral vein (Galen) 4: Basal vein (Rosenthal) 5: Superior petrous sinus 6: Cavernous sinus 7: Inferior petrous sinus 8: Bulb of internal jugular vein 9: Thalamostriate vein10: Internal cerebral vein11: Straight sinus 12: Transverse sinus 13: Sigmoid sinus
- Acute thromboembolic occlusion. Left internal carotid angiogram, early arterial phase, AP view, shows abrupt "cut-off" of the MCA . Lateral view, early arterial phase, shows normal filling of both ACAs and the ipsilateral PCA via a large PCoA. The MCA distribution is not opacified, leaving a large "bare area" of devascularized brain.
- Later image shows that the large "bare area" remains unopacified. Cortical branches are seen high over the left parietal convexity with early retrograde filling of the distal MCA branches via pial collaterals from the ACA and PCA. Collateral flow is also seen from the posterior temporal PCA branches into the MCA territory. (8-42D) Later image shows slow retrograde filling into the MCA territory from ACA and PCA collaterals.
- Capillary phase shows diffuse brain "blush" in ACA/PCA territories; contrast with "bare area" normally supplied by the MCA. Some MCA branches are filling slowly via retrograde flow from ACA/PCA pial collaterals. (8-42F) Venous phase shows persisting contrast in some MCA branches that have filled in retrograde fashion via pial collaterals and are slowly emptying. Note "blush" at border of "bare area" caused by "luxury perfusion."
- ICA Occlusion- Frontal projection from left cerebral angiogram delineates complete occlusion of left ICA to level of CCA. Normal opacification of ECA noted
- Cortical vein occlusion is shown with dural sinus thrombosis. (L) Coronal NECT in a 62y woman with headache, left-sided weakness shows a hyperdense SSS st and thrombus in the adjacent vein of Trolard ſt. (R) CTV shows "empty delta" sign in the SSS , filling defects in the vein of Trolard. (9-31) Close-up view of lateral DSA in the same case shows thrombus in SSS and vein of Trolard .
- Traumatic cervical ICA dissection. DSA shows the left ICA with greater than 50% luminal narrowing (arrows) with carotid terminus occlusion and lack of left anterior circulation filling (dashed circle).
- Carotid web in a 47-yearold woman with left cerebral infarction. (a, b) Coronal maximum intensity projection CT angiogram (a) and preintervention DSA image (b) show a focal linear shelflike filling defect (arrow) along the wall of the left ICA origin, consistent with a carotid web. (c) Postintervention DSA image shows that the web is no longer present.
- RCVS in a 30-year-old woman who presented with sudden-onset headache and no recent trauma. (a) DSA image shows multifocal narrowing (arrows) and beaded appearance of the anterior cerebral arteries and MCAs. (B) Follow-up DSA image at 10 days shows near-complete resolution.
- Known moyamoya in a young patient with prior watershed infarcts. Anteroposterior DSA image shows right ICA and proximal MCA steno-occlusive disease of the carotid termini (arrowheads), with extensive small collateral lenticulostriate arteries (arrow).
- Lateral left carotid angiogram in a patient with fibromuscular dysplasia. Note “string of pearls” appearance at around the C2 level.
- Angiograms of a patient with Takayasu arteritis demonstrating long, smooth stenotic lesions of the left subclavian artery and involvement of other branches of the aortic arch vessels. Lateral carotid angiogram demonstrates irregular beading appearance (arrowheads) of large and medium branches of the anterior, middle, and posterior cerebral arteries in a patient with systemic lupus erythematosus
- Sagittal NECT reformatted from the axial source data shows dense thrombus ſt extending throughout the entire deep venous (Galenic) system. The SSS appears normal. (D) Venous phase of the lateral carotid DSA in the same case shows normal cortical veins and SSS , vein of Trolard . The ependymal veins, ICVs, vein of Galen, and straight sinus are unopacified because they are completely filled with thrombus.
- Left MCA occlusion. (A) Initial lateral cerebral angiogram- Paucity of vessels in MCA distribution (B)- Repeat lateral angiogram after intra arterial lysis demonstrates recanalization of flow
- Mechanical thrombectomy with recanalization of the basilar artery but the left posterior cerebral artery remains occluded. A, Axial and, B, sagittal noncontrast head CT images show hyperattenuated thrombus (arrow) in the distal basilar artery. C, Coronal CT angi- ography shows nonopacity of the distal basilar artery (arrow). Left vertebral arteriogram in frontal projection, D, before and, E, after mechanical thrombectomy demonstrate recanalization of the basilar artery but occlusion of the left posterior cerebral artery (arrows). F, Axial diffusion-weighted imaging and, G, apparent diffusion coefficient map show acute infarct in the bilateral posterior cerebral artery territories with increased susceptibility in the left posterior cerebral artery (arrow on H) and, H, axial susceptibility-weighted imaging, mitigating against further mechanical thrombectomy attempts.
- Mechanical thrombectomy in intracranial atherosclerotic disease. A, Noncontrast head CT image on the axial plane shows multiple areas of subtle hypoattenuation in the right middle cerebral artery (MCA) distribution. B, Noncontrast head CT image on the axial plane shows calcified lesion in the right M1 middle cerebral artery (arrow). C, Time to maximum of residue function map on the axial plane shows large area of tissue at risk in the right MCA territory. Right common carotid arteriograms of, D, frontal and, E, lateral projections before attempted thrombectomy show occlusion of the distal M1 segment of the right MCA (arrow; thrombolysis in cerebral infarction score of 0). Right internal carotid arteriograms of, F, frontal and, G, lateral projections after three thrombectomy passes show antegrade flow through a high-grade stenosis (arrow) in the right distal M1 MCA
- A: Initial DSA showing thromboembolic occlusion of the right distal internal carotid artery (ICA). B: Mechanical thrombectomy of the right distal ICA and middle cerebral artery (MCA), which achieved complete recanalization. C: Diffusion-weighted MRI revealing an acute infarction in the right insula and basal ganglia. E: The patient suffered a second stroke 6 days after the index stroke; DSA revealing embolic occlusion of the left proximal MCA. F: The left MCA was successfully reopened after mechanical thrombectomy G: Follow-up diffusion weighted MRI revealing a slightly increased signal intensity in the left basal ganglia.