Two interesting angiography cases, illustrating the maxim that a good angiogram is worth a room full of speculating cardiologists.

1. CATH CONFERENCE 5FEB2015
FRANK MEISSNER, MD, RDMS, RDCS
FACP, FACC, FCCP, FASNC, CPHIMS, CCDS
2nd Law of Cardiology:
A Good Angiogram
Trumps A Room Full of
Speculating Cardiologists

2. XMAS EVE CHEST PAIN ED VISIT
SERIAL TROPONIN 24DEC@20:19 0.02 NG/DL;
24DEC@22:01 0.03 NG/DL; 25DEC04:03 0.41 NG/DL
65 y/o Hispanic Female No Previous Hx/o Chest Pain
CRF: HTN, Lipids, ex-13 yr smoker , postmenopausal
Transient (30 mins) Non-exertional Central Burning Pain,
Moderate Intensity, Mild Associated Dyspnea
No Hx/o GERD, Mild Bronchitic symptoms X 1wk
Mildly Obese, Soft S4, Mild Bronchial Breath Sounds
No Diagnostic Chest Xray or EKG Findings
No Chest Pain on Ward - Last Pain in ED

3. ATYPICAL NON-ANGINAL PAIN
NUCLEAR MEDICINE IMAGES

4. CAC SCORE
PROXIMAL LAD

5. MDCT AXIAL IMAGE
PROXIMAL LAD

6. CATH LAB IMAGE
11° RAO / 27° CAUDAL

7. CATH LAB IMAGE
36° RAO / 31° CRANIAL

8. CATH LAB IMAGE
35° RAO / 35° CAUDAL

9. CATH LAB IMAGE
17° RAO / 32° CAUDAL

10. RECURRENT SYNCOPE
30 Y/O REPAIRING HIS ROOF JULY 2014 FELL 14’
NECK & BACK PAIN POST TRAUMA SEQUELA
PREMONITION ABSENT SYNCOPE NOT CLEARLY
POSTURAL
NO CHEST PAIN, DYSPNEA, POUNDING PALPITATIONS
AFTER MULTIPLE SERIAL EVALUATIONS, HE
REPORTEED THAT SYNCOPE OR VISUAL BLACK OUT
WAS ASSOCIATED APPROX 50% OF THE TIME WITH
NECK TURNING (KEPT SYMPTOM DIARY)
NEGATIVE ECHO, NUC-TMT, CAROTID DOPPLER U/S,
CAROTID CTA, LEFT HEART CATH, TILT TABLE
TESTING, NO ARRHYTHMIA BY PROLONGED TELE
MONITORING
MRI CSPINE => CERVICAL MYELOPATHY &
CERVICAL 5-6 INSTABILITY

11. RIGHT VERTEBRAL
HEAD NEUTRAL HARD RIGHT TURN
No
Symptoms
Severe Dizziness
Visual Blackout

12. LEFT VERTEBRAL
HEAD NEUTRAL HARD RIGHT TURN
No
Symptoms
Severe Dizziness
L Sided Visual Blackout

13. BOW HUNTER’S SYNCOPE
SORENSON BF: BOW HUNTER’S STROKE. NEUROSURGERY 2:
259-261, 1978 - 1ST DESCRIPTION PATIENT DEVELOPED
HEMIPARESIS AND CONTRALATERAL SENSORY CHANGES
DURING ARCHERY PRACTICE.
BOW HUNTER’S SYNCOPE RARE FORM OF VBI PRESENTS AS
DIZZINESS, VERTIGO, SYNCOPE, NAUSEA, OR SENSORIMOTOR
DISTURBANCE DUE TO STENOSIS OR OCCLUSION OF THE
VERTEBRAL ARTERY FOLLOWING HEAD ROTATION ABOUT THE
CRANIO-CERVICAL AXIS
USUALLY OCCLUSION OCCURS AT THE C1 TO C2 LEVELS, BUT
LESIONS AT MULTIPLE LEVELS IN THE CERVICAL SPINE HAVE
BEEN REPORTED
CONCURRENT HYPOPLASTIC VA OR POOR CIRCLE OF WILLIS
COLLATERALIZATION CONTRIBUTING FACTOR TO SYMPTOM
PRODUCTION
CONCURRENT HYPOPLASTIC VA OR POOR CIRCLE OF WILLIS
COLLATERALIZATION CONTRIBUTING FACTOR TO SYMPTOM
PRODUCTION

14. 11/11/2014 - DR VELIMIROVIC
C5-6 DECOMPRESSIVE LAMINECTOMY + MEDIAL FACETECTOMY
AND PARTIAL BILATERAL FORAMINOTOMY
C5-6 POSTEROLATERAL ARTHRODESIS & SCREW FIXATION OF
C5-6
OPEN REDUCTION OF CERVICAL 5-6 INSTABILITY AND
DISLOCATION
OPEN REDUCTION OF CERVICAL 5-6 INSTABILITY AND
DISLOCATION
12/26/2014 - DR VELIMIROVIC
SPINAL ANGIOGRAM + CEREBRAL ANGIOGRAM WITH DYNAMIC
CERVICAL ANGIOGRAPHY — NO EVIDENCE OF VERTEBRAL
ARTERY OCCLUSION DURING PROVOCATIVE MANEUVERS
TO DATE NO FURTHER
SYNCOPE

15. DON’T TURN YOUR HEAD
HELTON, TJ & BAVRY AA. CIRCULATION.
2009, 120:E162.
IMAGES IN CARDIOVASCULAR MEDICINE
1st Law of Cardiology:
We Are All One Heart Beat
From Eternity.