Increased risk for complications following diagnostic cerebral angiography in older patients: Trends from the Nationwide Inpatient Sample (1999-2009)

Cerebral thromboembolic complications during cerebral angiography and their risk factors in different subgroups: Analysis of 2,457 procedures

PURPOSE

Diagnostic cerebral digital subtraction angiography (DSA) is an invasive examination that involves catheterization of the major supra-aortic arterial trunks and evaluation of intracranial vessels for diagnostic purposes. Although considered the gold standard method for investigating cerebrovascular diseases, DSA carries measurable and potentially serious complication rates. This report describes the frequency of neurological and non-neurological complications of DSA performed in five hospitals in the state of São Paulo, Brazil, and analyzes them in different disease subgroups. It has a special focus on thromboembolic cerebral complications.

METHODS

We retrospectively reviewed clinical records of all adult patients who underwent DSAs between January 2019 and December 2022. Demographic variables, DSA reports, CT/MRI reports, and clinical follow-up notes were reviewed.

RESULTS

Twenty-four patients experienced some type of complication among 2,457 diagnostic DSAs (0.97%). Thromboembolic complications were recorded in 9 patients (0.36%), and access site hematomas larger than 5 cm were registered in six patients (0.24%). There was a statistical trend for thromboembolic complications in patients with cervical and/or intracranial atherosclerosis (p = 0.07), but age was not associated with them (p = 0.93). Patients who received heparin had lower rates of embolic complications than those who did not receive it, but there was no statistically significant difference (p = 0.17). Intravenous administration of heparin showed a trend toward significance with groin hematoma (p = 0.10).

CONCLUSION

Diagnostic catheter DSAs have low complication rates.

Safety Aspects and Procedural Characteristics of Ambulatory Diagnostic Cerebral Catheter Angiography

PURPOSE

Diagnostic cerebral catheter angiography is used to assess a variety of neurovascular pathologies especially in patients before and after endovascular neurointerventional treatment. In many centers diagnostic cerebral angiographies are performed with the patient staying for one night in the hospital because there are not yet sufficient data on the safety of ambulatory cerebral angiography. At the same time hospitals face a growing demand to perform ambulatory medical procedures.

METHODS

A total of 426 ambulatory diagnostic cerebral angiographies were retrospectively analyzed. Technical details of the angiographies were analyzed to identify procedural risk factors.

RESULTS

Out of 426 patients 14 (3.3%) had some form of complication, 3 developed minor transient neurological symptoms, 1 patient developed Quincke's edema probably as an adverse reaction to contrast agent, 1 patient had an asymptomatic carotid dissection and 1 had a fall of unknown etiology. Of the 14 complications 8 were puncture site complications with 1 re-bleeding, 1 dissection, and 6 minor complications, 421 punctures were femoral, 3 radial and 2 brachial. Out of 333 patients with magnetic resonance imaging (MRI) after angiography 21 showed focal diffusion-weighted imaging (DWI) lesions but none of these lesions were symptomatic. The rate of DWI lesions was significantly higher in selectively angiography territories than in other territories. The use of a Simmons 2 catheter significantly increased the rate of DWI lesions (p = 0.047), whereas 3D rotational angiography did not (p = 0.55). The rate of DWI lesions per selectively accessed vessel was 4.6% with a higher rate in the anterior than in the posterior circulation.

CONCLUSION

Diagnostic cerebral catheter angiography can be safely performed in an ambulatory setting.

Association between diabetes mellitus and postoperative urinary retention after cerebral angiography

AIMS

The aim of this study is to examine the association between diabetes mellitus and postoperative urinary retention on cerebral angiography (including intravascular interventional therapy).

METHODS

We collected data on the demographic characteristics and comorbidities, imaging and routine laboratory data, surgical information, and medications of patients who underwent cerebral angiography. Multivariate logistic regression was used to explore the correlation between diabetes and the incidence of postoperative urinary retention.

RESULTS

A total of 932 patients were included, with a mean age of 59.7 years (74.1% men). Postoperative urinary retention occurred in 40.8% of the diabetes mellitus group and 30.3% of the group without diabetes. Compared with the group without diabetes, those with diabetes were more likely to experience postoperative urinary retention. Patients with higher glycosylated hemoglobin A1c levels had a higher risk of developing postoperative urinary retention.

CONCLUSIONS

Diabetes was independently linked to postoperative urinary retention following cerebral angiography and patients with glycosylated hemoglobin A1c levels > 6% were more likely to experience postoperative urinary retention. Therefore, clinically regulating blood glucose levels may help to reduce the likelihood of postoperative urinary retention after cerebral angiography.

Imaging modality-dependent carotid stenosis severity variations against intravascular ultrasound as a reference: Carotid Artery intravasculaR Ultrasound Study (CARUS)

PURPOSE

Different non-invasive and invasive imaging modalities are used to determine carotid artery stenosis severity that remains a principal parameter in clinical decision-making. We compared stenosis degree obtained with different modalities against vascular imaging gold standard, intravascular ultrasound, IVUS.

METHODS

300 consecutive patients (age 47-83 years, 192 men, 64% asymptomatic) with carotid artery stenosis of " ≥ 50%" referred for potential revascularization received as per study protocol (i) duplex ultrasound (DUS), (ii) computed tomography angiography (CTA), (iii) intraarterial quantitative angiography (iQA) and (iv) and (iv) IVUS. Correlation of measurements with IVUS (r), proportion of those concordant (within 10%) and proportion of under/overestimated were calculated along with recipient-operating-characteristics (ROC).

RESULTS

For IVUS area stenosis (AS) and IVUS minimal lumen area (MLA), there was only a moderate correlation with DUS velocities (peak-systolic, PSV; end-diastolic, EDV; r values of 0.42-0.51, p < 0.001 for all). CTA systematically underestimated both reference area and MLA (80.4% and 92.3% cases) but CTA error was lesser for AS (proportion concordant-57.4%; CTA under/overestimation-12.5%/30.1%). iQA diameter stenosis (DS) was found concordant with IVUS in 41.1% measurements (iQA under/overestimation 7.9%/51.0%). By univariate model, PSV (ROC area-under-the-curve, AUC, 0.77, cutoff 2.6 m/s), EDV (AUC 0.72, cutoff 0.71 m/s) and CTA-DS (AUC 0.83, cutoff 59.6%) were predictors of ≥ 50% DS by IVUS (p < 0.001 for all). Best predictor, however, of ≥ 50% DS by IVUS was stenosis severity evaluation by automated contrast column density measurement on iQA (AUC 0.87, cutoff 68%, p < 0.001). Regarding non-invasive techniques, CTA was the only independent diagnostic modality against IVUS on multivariate model (p = 0.008).

CONCLUSION

IVUS validation shows significant imaging modality-dependent variations in carotid stenosis severity determination.

Predictive value of the transcranial Doppler and mean arterial flow velocity for early detection of cerebral vasospasm in aneurysmal subarachnoid hemorrhage

Objectives

We aimed to predict cerebral vasospasm in acute aneurysmal subarachnoid hemorrhage and to determine the cut-off values of the mean flow velocity by the use of transcranial Doppler.

Methods

A total of 40 patients with acute aneurysmal subarachnoid hemorrhage were included in this study and classified into two groups. The first group was 26 patients (65%) with cerebral vasospasm and the second group was 14 patients (35%) without vasospasm. Initial evaluation using the Glasgow Coma Scale and the severity of aneurysmal subarachnoid hemorrhage was detected by using both the clinical Hunt and Hess and radiological Fisher grading scales. All patients underwent transcranial Doppler evaluations five times in 10 days measuring the mean flow velocities (MFV) of cerebral arteries.

Results

Patients with cerebral vasospasm were associated with significantly higher mean Glasgow Coma Scale score (p = 0.03), significantly higher mean Hunt and Hess scale grades (p = 0.04), with significantly higher mean diabetes mellitus (p = 0.03), significantly higher mean systolic blood pressure and diastolic blood pressure (p = 0.02 and p = 0.005 respectively) and significantly higher MFVs measured within the first 10 days. Logistic regression analysis demonstrated that MFV ≥81 cm/s in the middle cerebral artery is accompanied by an almost five-fold increased risk of vasospasm (OR 4.92, p < 0.01), while MFV ≥63 cm/s in the anterior cerebral artery is accompanied by a three-fold increased risk of vasospasm (OR 3.12, p < 0.01), and MFV ≥42 cm/s in the posterior cerebral artery is accompanied by a two-fold increased risk of vasospasm (OR 2.11, p < 0.05).

Conclusion

Transcranial Doppler is a useful tool for early detection, monitoring, and prediction of post subarachnoid vasospasm and valuable for early therapeutic intervention before irreversible ischemic neurological deficits take place.

Mechanical thrombectomy for acute occlusion of the posterior inferior cerebellar artery: A case report

BACKGROUND

Mechanical thrombectomy (MT) has been demonstrated to be useful for the treatment of ischemic stroke in patients with large vessel occlusions. However, recanalization by MT is not recommended for distal vessels such as second-order branches of the middle cerebral artery and posterior inferior cerebellar artery (PICA). Because of the small size and tortuosity of these arteries, the risks of using the available endovascular devices outweigh the benefits of treatment. However, MT appears to be effective in patients with primary distal vessel occlusion in eloquent areas, those with a high National Institutes of Health Stroke Scale score, and those ineligible for recombinant tissue plasminogen activator therapy. Here, we report the use of MT for treating acute occlusion of the PICA using a direct-aspiration first-pass technique (ADAPT).

CASE SUMMARY

In this case, the patient received acute occlusion of the PICA with ADAPT when right internal carotid artery stenting was performed.

CONCLUSION

With the introduction of advanced endovascular devices, MT may now be a feasible treatment for acute occlusion of the PICA.

Emergent surgical embolectomy for middle cerebral artery occlusion related to cerebral angiography followed by neck clipping for an unruptured aneurysm in the anterior communicating artery

Background:

Intracranial embolism related to cerebral angiography is rare but one of the complications of the procedure. However, the standard management of acute intracranial embolism for this etiology has not been established, and there have been very few reports in the past.

Case Description:

A 68-year-old male was incidentally found to have an unruptured aneurysm of anterior communicating artery (ACoA). Immediately after the cerebral angiography for the purpose of detailed examination of the aneurysm, the right partial hemiparalysis and mild aphasia developed. Magnetic resonance imaging/angiography (MRI/A) revealed an occlusion in the peripheral part of the left middle cerebral artery (MCA). Due to the existence of magnetic resonance angiography-diffusion mismatch, emergent craniotomy was immediately performed to remove intra-arterial thrombus. We also performed clipping for an unruptured ACoA aneurysm with this approach. Postoperative MRI/A showed that the occluded artery was recanalized and a slight infarction was observed in the left cerebral hemisphere. The patient was discharged on foot and followed at outpatient clinic over 4 years without no neurological deficit.

Conclusion:

Emergent surgical embolectomy for distal MCA occlusion related to cerebral angiography followed by neck clipping for an unruptured aneurysm of the ACoA was successful in treating acute occlusion of the peripheral part of the MCA in a patient with an unruptured aneurysm. As there are few similar cases, there is controversy about the best management, but this surgical method can be a safe and effective treatment.

The role of computed tomography angiography as initial imaging tool for acute hemorrhage in the head and neck

OBJECTIVES

Acute hemorrhage in the head and neck (AHNH) is life-threatening due to asphyxiation and hemorrhagic shock. When conservative measures fail, some patients benefit from endovascular therapy (EVT). While CTA is routinely used to localize bleeding and plan EVT in gastrointestinal hemorrhage, the diagnostic value of CTA in AHNH and role of CTA in treatment-planning are uncertain.

METHODS

We retrospectively reviewed neck CTAs from June 2015 to October 2018 indicated for AHNH. When performed, digital subtraction angiography (DSA) findings and EVT were documented. Extravasation or pseudoaneurysm on DSA was considered positive for bleed localization.

RESULTS

Thirty CTA exams were performed for AHNH in 18 patients (mean age = 56.6, male% = 55.6%). Eleven out of 30 exams (36.7%) had immediate DSA follow-up within 24 h. Etiologies of hemorrhage included malignancy 11/18 (61.1%) and coagulopathy (4/18, 22.2%) among others. CTA reports identified definite or possible source of bleeding in 7/30 (23.3%) exams. Seven out of 7 (100%) patients with definite or possible source of bleeding on CTA underwent DSA and 4/23 (17.4%) patients underwent DSA despite negative CTA. With DSA as the gold standard, CTA had a sensitivity of 70% and a specificity of 100%.

CONCLUSIONS

CTA has high specificity and reasonable sensitivity for detecting arterial source of bleeding in patients presenting with AHNH. Patients with negative CTA may avoid catheter angiography in most cases; however, false-negative CTA should not preclude angiography in high-risk patients.

The Utility of a Diagnostic Angiogram Following Mechanical Thrombectomy for Treatment of Acute Ischemic Stroke

OBJECTIVE

Digital subtraction angiography is the gold standard for diagnosis of vascular pathology. The value of angiography of non-target vessels following mechanical thrombectomy for the treatment of acute ischemic stroke (AIS) is unknown.

PATIENTS AND METHODS

Consecutive patients treated with mechanical thrombectomy for AIS due to large vessel occlusion (LVO) at an academic institution between February 2016 and December 2018 were retrospectively reviewed. Demographic information, clinical data, and procedure details were recorded. Descriptive statistics were used to evaluate the utility of non-target vessel angiography.

RESULTS

One hundred and fifty-six patients presenting with AIS due to LVO were treated with 159 mechanical thrombectomy procedures. Median age was 71.5 years. Ninety-one (57.2%) procedures were followed with a diagnostic cerebral angiogram of non-target vessels. Previously unknown findings were identified in 4 (4.4%) procedures. Management change due to the non-target vessel angiogram finding occurred in 3 (3.3%) cases and included one contralateral mechanical thrombectomy. No complications occurred as a result of the non-target vessel angiogram.

CONCLUSION

Angiographic imaging of non-target vessels following mechanical thrombectomy identified previously unknown vascular pathology in 4.4% of procedures and resulted in a clinical management change in 3.3% of cases.

A Closer Look at Angiitis of the central nervous system

Angiitis of the central nervous system (ACNS) is a rather new disease entity that is defined as vascular inflammation limited to the central nervous system and was formally nominated in 1959. Etiologically, it can be divided into primary and secondary ACNS. However, the potential pathogenesis of ACNS remains unclear. The clinical presentation is variable, and there is no consensus concerning its diagnosis and management. Although the incidence is relatively low, ACNS is still a life-threatening condition. It is essential to get a comprehensive and updated understanding of the disease. In this paper, we reviewed the history, definition, classification, pathogenesis, and clinical manifestations of ACNS. In addition, we focused on the latest investigations and viewpoints regarding the diagnosis and treatment of ACNS.

CT angiogram negative perimesencephalic subarachnoid hemorrhage: is a subsequent DSA necessary? A systematic review

Background

Perimesencephalic subarachnoid hemorrhage (PMSAH) is a benign subtype with distinct clinical-radiologic features. Digital subtraction angiography (DSA) remains the gold standard investigation for exclusion of a macrovascular cause, although increasingly more clinicians rely solely on CT angiography (CTA). The primary aim of this systematic review was to evaluate the current literature regarding the negative predictive value of CTA.

Methods

A systematic search in concordance with the PRISMA checklist was performed for studies published between 2000 and 2018. Studies with ≥10 adult patients diagnosed on a non-contrast brain CT with a PMSAH, who underwent a negative CTA and were subsequently subject to a DSA, were included. Simple pooled analysis was performed to inform the negative predictive value (95% CI) of CTA and the risk of DSA- and CTA-related complications.

Results

Eighteen studies (669 patients) were included. All patients were subject to at least one DSA, the first one mostly performed within 24 hours of CTA (68.6%). 144 patients (21.5%) underwent a second DSA and a third repeat DSA was performed in one patient. The overall negative predictive value of CTA was 99.0% (95% CI 97.8% to 99.5%). The risk of complications following DSA and CTA were 1.35% (3/222) and 0% (0/41), respectively.

Conclusions

Undertaking a DSA after a negative CTA may not add any further diagnostic value in patients with PMSAH and may lead to net harm. This observation needs to be validated in a large-scale prospective multicenter study with complete case ascertainment and robust data on CTA and DSA complications.